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THE 

JOURNAL 



OF 



Nervous and Mental Disease 



A MONTHLY PERIODICAL 

EDITED BY 

CHAS. HENRY BROWN, M.D., 

NEW YORK, 
WITH THE ACTIVE CO-OPERATION OF 

W. R. Birdsall, M.D., L. Fiske Brtson, M.D., C. L. Dana, M.D., Matthew D. 
Field, M.D., L. C. Gray, M.D., Graeme M. Hammond, M. D., A.McLane 
Hamilton, M.D., Christian A. Herter, M.D., C. F. Macdonald, M.D., 
W. J. Morton, M.D., Grace I'eckham, M.D., Frederick Peterson, 
M.D., New York ; Prof. Burt G. Wilder, M.D., Ithaca, N.Y. ; 
Wm. A. Hammond.M.D., Washington, D. C. ; Morton- 
Prince, M. D., Boston ; J. G. Kiernan, M.U., 
Chicago; Frank R. Fry, M.D., St. Louis, Mo. ; 
C. Eugene Riggs, M.D., St. Paul, Minn.; 
C. K.Mills. M D Philadelphia; 
Isa^C OrT. M D. Easron 
Pa ; and others 

• ] 

VOLUME XV., (New Series), 1890. 

[whole SERIES VOL. XVII.] 



AMS PRESS, INC. 
NEW YORK 



Reprinted with permission of 
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INDEX TO VOL. XV. 

(NEW SERIES.) 



ORIGINAL ARTICLES. 

PAGE 

Three Diagnostic Signs of Melancholia. By Lanolon Carter Gray, M.D. i 

A Case of Cervical Paraplegia from Dislocation — Autopsy. (Illus- 
trated.) By Christian A. Herter, M.D 10 

A Contribution to the Clinical Study of Spontaneous Degenerative Neu- 
ritis of the Brachial Plexus. (Illustrated.) By William M. Les- 
zynsky, M.D ' 18 

Hemorrhage into the Cerebellum and Fourth Ventricle, and by Exten- 
sion into the Third and Lateral Ventricles. By Charles K. Mills, 
M.D 43 

Paralysis of Serratus Magnus. (Illustrated.) By Ross R. Bunting, M.D. 67 

The Knee-jerk After Section of the Spinal Cord. By Edward T. Reich- 

ert, M.D 71 

A Case of Acute Melancholia, During the Progress of Which There Ap- 
peared Argyle-Robertson Pupil, with Abolished Patellar Reflexion 
on One Side "and Much Diminished on the Other. By H. A. Tom- 
linson, M.D. . . ., 75 

Trephining for Extra-Dural Haemorrhage. By John B. Deaver, M.D. 83 

Two Cases of Paralysis Occurring During the Puerperal State. By 

M. Imogene Bassette, M.D 93 

Morphine Injections Followed By Emphysematous Gangrene (Malig- 
nant Oedema). By L. Bremer, M.D. 97 

Notes on Some Cases of Chorea and Tremor. (Illustrated.) By Chas. 

K. Mills. M.D 131 

Congenital Bilateral Pleuroplegia and Facial Paralysis. (Illustrated.) 

By A. Schapringer, M.D 143 

A Case of Multiple Cerebral Softening, Widespread Endarteritis, Dis- 
secting Aneurism of Branch of Lett Middle Cerebral Artery. (Illus- 
trated.) By Christian A. Herter, M.D 150 

A Contribution to the Study of Epilepsy. By Frank H. Ingram, M.D. 165 

Reports of Six Cases of Friedreich's Ataxia. Occurring in Three Differ- 
ent Families. By Chas. W. Rook, M.D.. and Chas. L. Dana, M.D. 173 

Report of the Committee of the New York Neurological Society upon 

the Gallup Lunacy Bill ' 181 

A Case of Ophthalmic Migraine. By J. Chalmers Da Costa, M.D 217 

Remarks on the Pathology of Chorea. By F. D. Fisher, M.D 221 

Specimen Showing Anomaly of the Circle of Willis. (Illustrated.) By 

James Hendrie Lloyd, M.D 225 

Functional Nervous Diseases and their Relations to Gastro-Intestinal 

Derangements. By W. H. Thomson, M.D 227 

Hypnotism. By Frederick Batcman, M.D., F.R.C.P 287 

A Study of Cerebral Palsies of Early Fife, Based Upon an Analysis of 
One Hundred and Forty Cases. (Illustrated. 1 By 15. Sachs, M.D. 
and F. Peterson. M.D 295 

The Rational Treatment of Sciatica. By Graeme M. Hammond, M.D. 333 

The Minute Structure of the Gray Nerve Tissue. (Illustrated.) By 

C. Heitzman, M.D 357 

Hysterical Fever. (Illustrated.) By Mary Putnam Jacobi, M.D 373 



IHDEX. hi 

A Case of Chorea attended with Multiple Neuritis. By Frank R. Fry, 

A.M., M.D 389 

Notes on the Action of Gelsemium in Some Local Spasms and Neural- 
gias. By M. Imogene Bassette, M.D 395 

Report of an Interesting Case of Feigned Insanity. By M. D. Field, M.D. 401 

Unusual Cases of Chorea, Possibly Involving the Spinal Cord. By 

S. Weir Mitchell. M.D. and Chas. W. Burr. M.D 427 

Contribution to the Study of the Traumatic Xeuro-Psvchoses. By 

G. L. Walton, M.D 432 

A Case of Locomotor Ataxia Associated with Nuclear Cranial Nerve 
Palsies and with Muscular Atrophies. (Illustrated.) By Freder- 
ick Peterson, M.D 450 

A Contribution to the Pathology of the Laryngeal and other Crises in 

Tabes Dorsalis. By Ira Van Giesen, M.D 458 

A Form of Poly-Neuritis, Probably Analogous to or Identical with Beri- 
Beri Occurring in Sea-Faring Men in Northern Latitudes. By 
James J. Putnam, M.D 495 

Tumor of the Thalamus, More Especially of the Pulvinar, Presenting 

Wernicke's Pupil Reaction. By F. X. Dercum, M.D 506 

Report of Cases Illustrating Cerebral Localization. (Illustrated.) By 

J. H. McBride, M.D. 512 

A Contribution to the Therapeutics of Spastic Paralysis. By V. P. 

Gibney, M.D 520 

A Case of Insular Sclerosis, in which an Attack of Cerebral Hemor- 
rhage Arrested the Tremor on the Hemiplegic Side. By Wharton 
Sinkler, M.D 524 

The Hypnotic State of Hysteria. By William C. Krauss, M.D 526 

Progressive Senile Paraplegia: A Contribution to the Study of Non- 
inflammatory Softening of the Cord. (Illustrated.) By Chas. L. 
Dana, M.D 563 

Two Cases of Svripgomyelia. (Illustrated.) By John Amory Jef- 
fries. M.D. 568 

Cases of Hysteria Treated by Hypnotism. By S. G. Webber, M.D. . . 585 

A Case of Focal Hemorrhagic Lesion of the Prepeduncle (Anterior Cere- 
bellar Peduncle). By H. M. Bannister, M.D 597 

On the Germ of a Communicable Disease derived from a Dog, alleged 
to have died of Rabies, which retains Rabies Characters. By 
Richard Mollenhauer, M.D 604 

Acute Myelitis, preceded by Acute Optic Neuritis. By J. T. Esk- 

ridge, M.D 609 

A Contribution to the Pathology of Solitary Tubercle of the Spinal 

Cord. By Christian A. Herter, M.D 631 

On Gold Chloride as a Staining Agent for Nerve Tissues. (Illustrated.) 

By Henry S. Upson, M.D 646 

Two Cases of Friedreich's Disease. By Chas. Henry Brown, M.D . . . 657 

Clinical Evidences of Borderland Insanity. By Irving C. Rosse, M.D. 669 

Two Cases of Tumor of the Cerebellum. (Illustrated.) By J. Arthur 

Booth, M.D 684 

Diffuse Cortical Sclerosis of the Brain in Children. Bv Win. N. Bill- 
iard, M.D 699 

Brachio-Facial Monospasm, following Probable Embolism, with Conse- 
quent Degenerative Changes in Brain and Localized Meningitis — 
Death from Apoplexy. (Illustrated.) By Morris J. Lewis, M.D. 710 

A Case of Tubercular Meningitis, with Autopsv. By Win. Broaddus 

• Pritchard, M.D 720 

A New Electropion. By Chas. Henry Brown, M.D 727 

A Case of Spina Bifida with Suppurative Spinal Meningitis and Ependy- 
mitis, Due to Bacteria Entering the Wall of the Sac. By L. Em- 
met Holt, M.D. and Ira Van Giesen, M.D 774 

.V Study of Heat-Production and Heat-Dissipation in the Normal and 

Febrile States. By William A. Carter, M.D 782 

Treatment of Epilepsy. By Philip Zenner. A.M., M.D 769 



VOL. XV. January, 1890. No. 1 

THE 

Journal 

OF 

Nervous and Mental Disease. 



Original Articles. 



THREE DIAGNOSTIC SIGNS OF MELANCHOLIA. 1 

By LANDON CARTER GRAY, M.D., 

Professor of Nervous and Mental Disease in the New York Polyclinic. 

TRUE melancholia may be divided into simple melan- 
cholia, melancholia agitata, melancholia attonita, 
and melancholia with stupor. It is mainly of the 
first of these forms, of the slighter cases of the second form 
and of some few cases of the fourth type that I propose to 
speak. In the simple form of melancholia, as we all very 
well know, there is a melancholy, which is usually unat- 
t.r.^ed by delusions, hallucinations or illusions, although 
there may occasionally be delusional or hallucinatory ten- 
dencies, but there is none of the agitation or stupor of the 
other forms. The simple forms of melancholia are often 
extremely difficult to diagnosticate, especially in the early 
stage, as the reasoning powers, the memory, and the per- 
ceptions are then often seemingly unimpaired, or not more 
affected than is possible from a myriad unimportant causes. 
Patients suffering from this mental disease too frequently 
figure as neurasthenics, to be confidently treated as such 
until some determined and frightful suicidal or homicido- 
suicidal attempt throws startling light upon the true nature 
of the malady. These, too, are the cases of unaccountable 

1 Read before the American Neurological Association, June 28, 1889, at Long 
Branch. 



2 LANDON CARTER GRAY. 

suicides which puzzled friends and competing newspaper 
reporters account for so satisfactorily and sensationally upon 
some theory of rejected love or high-flown sentimentalism. 
Any certain diagnostic symptoms in this class of cases 
should be for these reasons of value. In sixteen cases of mel- 
ancholia of the above types which I have had under obser- 
vation in the last eighteen months, I have found three 
constant symptoms, viz., the melancholia, marked insomnia, 
and a post-cervical ache. 

The melancholy is different from simple sadness. In 
the latter there is some cause for the mental depression 
which the patient recognizes and seeks to have removed, 
and the mental faculties are not at all affected. In melan- 
cholia, on the contrary, there is seldom any adequate cause 
for the depression which the patient will often not recog- 
nize the presence of, and about the treatment of which he 
or she is often utterly indifferent, if indeed, he or she be not 
obstinately opposed to any treatment ; and a careful exam- 
ination will show a certain dullness of mental reflex, made 
perceptible by slower responsive acts or words than is usual 
to a healthy mind. In the more marked cases of simple 
melancholia, especially in those bordering upon the agitated 
and stupid types, careful and close questioning will elicit 
from the patient a history of delusion and hallucinations — 
rarely illusions, if I may judge by my own experience — of a 
melancholy and more or less terrifying nature. The char- 
acteristics of this peculiar melancholy — the causelessness, 
the indifference, the slow mental reflexes, with the occa- 
sional history of terrifying delusions and hallucinations — 
are remarkably constant, and they are so significant that I 
have again and again based upon them a diagnosis which 
further examination has verified. 

The post-cervical ache is, as I have indicated by the 
name which I have ventured to give it, an aching pain in 
the back of the neck, head, and sometimes into the shoul- 
ders. It is usually described as a distress or ache, although 
it may occasionally be neuralgic in its character, and not 
infrequently passes into neuralgic paroxysms which will 
last for a day or two. 



DIAGNOSTIC SIGNS OS MELANCHOLIA. 3 

The insomnia is usually one of the earliest symptoms of 

the disease, but has no especial characteristics of which I 

am aware. 

The following histories will demonstrate that these three 

conjoined symptoms of melancholia, insomnia and post- 
cervical ache were constant. 

CASE I. — Miss , age thirty-five, had a severe attack 

of melancholia three years ago, caused by the sudden 
death, by a fall from his horse a few days before the 
intended marriage, of the gentleman to whom she was 
betrothed. The melancholia lasted for upwards of a year, 
and it was not until about a year ago that she came under 
my care. She then complained greatly of obstinate insom- 
nia, and severe aching in the back of the head and neck. 
For a year this patient has been under my treatment, so 
that I have been able to observe in her the existence of a 
fixed melancholy, of such a nature that it seems utterly 
impossible for her to receive a pleasant impression of any 
kind. At times she has attacks of dull aching pain in the 
back part of the head, neck and shoulders, and at the same 
time she becomes more or less sleepless. These attacks 
have usually been mild in character, and have yielded after 
about a week of treatment, but occasionally they have 
become very severe, and the post-cervical ache has become 
actual pain of considerable intensity, the insomnia has 
become pronounced, and the melancholiac condition had 
deepened and has been attended with mental confusion and 
hallucinations. 

Case II. — Mrs. B., widow, had attack of melancholia 
agitata about eight years ago, during which she made 
repeated and determined attempts at suicide. When I saw 
her a year or two after the acute symptoms had disappeared 
she had a fixed melancholy which no reasoning could influ- 
ence ; slept only three or four hours each night, and was 
troubled with a constant aching, uneasy feeling in the back 
of the neck and head and in the shoulders. During the 
years that have since elapsed, in which this patient has 
either been under my care or so situated that I have known 
accurately of her condition, she has had almost uninter- 
ruptedly the fixed melancholy, the poor sleep and the 
post-cervical aching. At times the insomnia has become 
very obstinate, and the post-cervical ache has mounted into 
severe neuralgic distress, but she has had no increase of her 
mental symptoms. 



A LANDON CARTER GRA Y. 

Case III. — Mrs. M., sent to me September, 1888, by a 
physician. She gave a history of a meningitis following 
insulation many years ago. During the last six months 
she has been suffering from melancholia, obstinate insom- 
nia, slight hallucinations, and constant distressing aching 
in the back of the head and neck and in the shoulders. 
Under treatment these symptoms disappeared, with the 
exception of some slight aching in the locality described, 
and the patient was doing very well when she was again 
sunstruck in the early part of the summer, and had another 
attack of meningitis, since when I have lost sight of her. 

Case IV. — Miss , brought to me by a physician, 

had had melancholia for some two months, and had made 
two determined attempts at suicide. She had a causeless 
melancholy which could not be reasoned away, but had 
never had any hallucinations or mental confusion, had 
obstinate insomnia, and well-marked aching in the back of 
the head and neck and in the shoulders. This patient has 
improved very greatly during the year that has since elapsed, 
I am told, but she still suffers from her melancholy, occa- 
sional insomnia, but I have not been able to inform myself 
in regard to the post-cervical aching, as I have never seen 
her but upon the one occasion of the consultation with her 
attending physician. 

Case V. — Miss , age forty, seen in consultation in a 

neighboring city. She has a causeless melancholy, slight 
hallucinatory tendencies, has talked longingly of suicide, 
but has made no attempt at it ; has suffered from obstinate 
insomnia, and has considerable distress in the back of the 
head. This patient refused to be treated, and I know 
nothing further accurately of her history. 

Case VI. — Miss , age thirty-two, seen in consulta- 
tion. She had had slight melancholy, entirely cause- 
less ; had spoken about suicide, but never made any 
attempt at it ; suffered from insomnia tor about two 
weeks, and also from distress in the back of the head 
and neck. This case had made an excellent recovery in 
some six weeks under treatment of the attending physician, 
and when I saw her in consultation she was only suffering 
from the distress in the back of the head and from slight 
melancholy. This was altogether one of the mildest cases 
that I have ever seen in my life. 



DIAGNOSTIC SIGNS OF MELANCHOLIA. 5 

Case VII. — Miss , age twenty-five. This patient 

had a severe attack of melancholia, with considerable agi- 
tation, obstinate insomnia, marked suicidal tendencies, but 
manifested no symptoms of the post-cervical aching. I 
attended her for some eight weeks, during which her con- 
dition did not materially improve, except that the insomnia 
was successfully combatted with hypnotics. She then 
passed out of my charge ; whether she afterwards had a 
post-cervical ache or not, I am unable to say, or as to what 
her further symptoms were. 

Case VIII. — Miss , age twenty. This was a case 

of mild melancholia agitata, with marked melancholia and 
melancholy hallucinations and some slight mental confu- 
sion. This patient committed suicide in a most determined 
and seemingly intelligent manner by taking the poison 
known as "Rough on Rats." 

CASE IX. — Mr. , age sixty-seven. This patient is 

suffering at the present time from melancholia, with marked 
suicidal and homicidal tendencies, slight hallucinations and 
great insomnia, but has no post-cervical ache. 

Case X. — Mr. , age thirty-seven. Came to my 

office complaining of pain in the back of the head and 
neck. Something in the man's manner aroused my suspi- 
cions, and I found that he had, about six years ago, whilst 
living in Further India, an attack of melancholia with 
obstinate insomnia, slight mental confusion for a short 
time, and suicidal tendencies, all these symptoms having 
lasted about six months, and since this time he has had an 
aching post-cervically, which often passes away and leaves 
only a neuralgia over the left ear and scalp. This patient 
is still under treatment. 

Case XI. — Mr. , age thirty-four, is very melancholy 

and apprehensive, has obstinate insomnia, sleeping about 
four hours with large doses of sulphonal, and has a constant 
drawing pain in the neck and shoulders. Xo suicidal ten- 
dencies. This patient is still under treatment. 

Case XII. — Miss , age twenty-eight. Seen in con- 

sulation in a neighboring city. For about a year has had 
constant and great insomnia, pronounced melancholy, 
occasionally becoming greatly agitated and so marked that 
the patient would shut herself up in her room and cry 



6 LANDON CARTER GRAY. 

incessantly. Has constant pain in the occiput, which is at 
times quite severe. Has slight delusions. 

Case XIII. — Miss , age thirty. Great melancholy 

for the last six months and obstinate insomnia for the same 
time. Has a weary aching feeling over the back and the 
top of the head. During the last ten years she has had 
several similar attacks, lasting two to three months, with 
insomnia, aching post-cervically and at the vertex. In one 
of these attacks she had a hallucination of sight, otherwise 
no hallucinations or delusions in any of these attacks. Has 
had suicidal ideas frequently suggest themslves to her, but 
has been able to repel them. 

Case XIV. — Mrs. , age forty-two, wife of a physi- 
cian, came to me complaining of great aching distress in 
the back of the head and shoulders. This led me to inter- 
rogate her closely, when I found that she had just recov- 
ered from an attack of typical melancholia with obstinate 
insomnia, marked suicidal and homicidal tendencies, which 
nothing but her strong religious feelings had enabled her 
to control, and which she had suffered for some six months 
without daring to tell her husband. This patient is still 
under treatment, and is almost recovered from the aching 
and the occasional attack of melancholy which were all 
that have been left of her former attack. 

Case XV. — Mrs. , age thirty-three, sent to me by 

a physician. About nine months ago was attacked with 
melancholia shortly after severe domestic misfortune, suf- 
fered for three consecutive nights absolute sleeplessness 
and then began to suffer from pain in the back of the head 
and down the spine. Since the onset the melancholy and 
the ache have been present almost the whole time, but the 
insomnia has been treated with fair success, although she 
still sleeps badly and is a long time in getting to sleep. At 
first she had optic hallucinations occasionally. 

Case XVI — Miss , age twenty-six. About one 

year ago, after great worriment and night work in nursing 
her mother, she began to be very sleepless, and to have an 
aching feeling in the back of the neck and become very 
melancholy. In the last three months she has heard a 
constant crackling sound at the back of the head. Has 
never had the slightest suicidal feeling. 




DIAGNOSTIC SIGNS OF MELANCHOIIA. J 

In cases of melancholia with stupor and the melancholia 
attonita, I have not been able to ascertain whether or not 
the post-cervical ache was felt, possibly because of the 
stupor, but I do not think that these cases complain of it 
after recovery. In the cases of simple melancholia and the 
milder cases of agitated melancholia, the post-cervical ache 
is apt to last for many years in certain patients after the 
main disease has been entirely removed, and in some of 
this class it will occasionally merge into violent neuralgic 
attacks, during which the insomnia will return, and there 
may supervene some slight mental confusion and melan- 
cholia, although these recurrent attacks seldom last over a 
week, and are very easily treated. The insomnia is apt to 
be an obstinate symptom for a certain length of time in all 
the forms, but the cases of melancholia attonita and stupid 
melancholia do not suffer from insomnia after they have 
recovered from the main disease as much as do the cases of 
simple melancholia and the slighter cases of the agitated 
form. In the latter two classes it is not unusual to find 
patients suffering constantly from slight insomnia for many 
years, and at times becoming so sleepless as to necessitate 
large doses of hypnotics. 

So firmly have I come to rely upon the association of 
this symptomatic triad that I have lately made a diagnosis 
in two cases by means of it. The first patient was a gen- 
tleman who came to me complaining of a distress in the 
back of the head and neck, which at times was painful. 
I learned from him that the onset dated back to six years 
ago, when, as he said, he had been run down and de- 
pressed. I then told him that I would outline to him his 
symptoms at that time, and I proceeded to tell him that he 
had been very very much depressed, had not been able to 
sleep, had thought of committing suicide, had been slightly 
confused in mind, and had remained in this condition for 
several months. He was amazed, and asked me if I was a 
mind reader, finally admitting that he had passed through 
just such an attack of melancholia, which he had concealed 
from everybody because he was then living in Burmah in 
the employ of the English Government, and was afraid that 



8 LANDON CARTER GRAY. 

he would lose his position if they should think him insane. 
The other patient was a lady who came to me complaining 
of the same vague distress in the back of her head and 
neck. I also ascertained from her that the trouble dated 
back some six months ; and I then asked her whether she 
had not at the beginning been very much depressed. She 
answered me in the affirmative with so embarrassed an air 
as to make me assured that there was something concealed, 
and I then went on to recapitulate to her the symptoms of 
melancholia as I had done to the man from Burmah. She 
burst into tears, and admitted that she also had passed 
through an attack of melancholia, and astonished me in 
her turn by telling me that she was the wife of a well- 
known physician, and that she had concealed all knowledge 
of her mental condition from her husband, because she was 
afraid that he would send her to an asylum. This poor 
woman had absolutely on several occasions felt so strong 
an impulse to kill her children and herself that she had 
been obliged to leave the house and get away from them. 

It seems to me that the knowledge of this conjunction 
of symptoms should be of value for both diagnostic and 
therapeutic reasons. Every physician in general practice, 
and still more every neurologist, knows how difficult it is at 
times to feel sure as to whether a given case of depression is 
one of hysteria, of grief, of depression from a gastro- 
intestinal disorder, of depression preceding the outbreak of 
some other form of mental disease, or whether it is true 
melancholia. In the latter the suicidal and homicido- 
suicidal tendencies are so organic a part of the disease that 
the mildest case is not to be trusted, and valuable lives 
may be saved by some method of prompt recognition. I 
have no hesitation in saying that the most ghastly crimes 
in the annals of lunacy are those which are committed by 
melancholiacs who are suffering from simple melancholy, 
without stupor and either without delusion or hallucination 
or with slight tendencies of the two latter kinds, for these 
patients seem so reasonable and intelligent that no check is 
put upon them, and they attain their diabolical ends with a 
directness and success that is not possible to any other 



DIAGNOSTIC SIGNS OF MELANCHOLIA. 9 

class of the insane. I have known of one patient secreting 
for months a match under her thumb nail and a wisp of 
light paper in her axilla, finally to draw out the paper and 
light it with the end of the match and deliberately set fire 
to her gown so as to burn herself to death. I have known 
another patient, who had been watched for weeks, but who 
had seemed perfectly quiet and inoffensive, yet slink out of 
the house at midday, walk two miles to the Park, deliber- 
ately search for the most secluded part in it, remove 
his shirt and tear it into strips, make a rope of the pieces, 
and hang himself to the bough of a tree. And I could go 
on multiplying instances, which all of you could probably 
match, of women who have killed their children, of hus- 
bands who have killed their wives, of lovers who have 
killed the beloved, until the recital of horrors would equal 
the bloody reign of the Duke of Alva and the Inquisition in 
the Netherlands. From a therapeutic point of view the 
recognition of the insomnia and the post-cervical ache 
should enable a physician to diminish the distress and the 
consequent aggravation of mental symptoms. 

I venture to hope that the medical profession will 
observe this triad of symptoms, so that we may ascertain 
the percentage of its presence in a greater number of cases 
than it has fallen to my fortune to observe. 
New York, 6 E. 49TH St. 



A CASE OF CERVICAL PARAPLEGIA FROM 
DISLOCATION— AUTOPSY. » 

By CHRISTIAN A. HERTER, M.D. 

THE following is the history of a case of cervical para- 
plegia from dislocation forward of the sixth cervical 
vertebra upon the seventh. The patient was in the 
Presbyterian Hospital in the service of Dr. Briddon,to whom 
I am indebted for an opportunity of examining the case. 

J. F., a mason, fifty-seven years of age, fell head first 
from, a scaffolding on the morning of October 9, 1889, a 
distance of twelve feet. 

His head struck against a board, but precisely in what 
manner is not known. 

When found the patient lay on his back in great agony. 
He referred his pain to his neck. 

On admission to the hospital the patient was still fully 
conscious. Respiration was purely diaphragmatic. The 
pulse was good. Temperature 97. 2° 

A careful examination failed to elicit evidence of fracture 
or dislocation in any part of the cervical spine. It was 
noted, however, that there was great tenderness to pressure 
over the sixth and seventh cervical vertebrae. 

The house-surgeon, Dr. Sharpe, states that when first 
admitted the patient was observed to have good use of his 
forearms and arms, although he was completely paraplegic 
below the upper extremities, and the fingers were weak. 
There were also complete anaesthesia and analgesia of the 
lower extremities, and of the trunk as high as the seventh 
cervical vertebra behind, the exact upper limit of the sen- 
sory loss anteriorly not having been noted. The loss of 
sensibility also involved the ulnar border of either upper 
extremity. 

' Read before the New York Neurological Society, 1889. 



CERVICAL PARAPLEGIA. I I 

With the exception of the plantar reflex of the left side, 
both superficial and deep reflexes were absent when the 
patient first came under observation. 

Nine hours after the admission of the patient an exam- 
ination was made to determine with exactness the distribu- 
tion of the motor and sensory paralysis, in order to learn 
the upper level of the lesion in the cord. 

There was complete paralysis of motion below the level 
of the upper extremities. In the upper extremities them- 
selves there was complete loss of power in the intrinsic 
muscles of the hand and interossei, in the flexors and 
extensors of the wrist and in the triceps. There was slight 
loss of power in the pronators and supinators, and consid- 
erable weakness of the biceps. The weakness of the biceps 
was more pronounced on the left than on the right side ; in 
other respects the distribution of the motor loss was highly 
symmetrical. 

The house-surgeon stated that the weakness of the 
biceps at the time of this examination was distinctly greater 
than three hours before, and also that the muscles of the 
hand were involved before those of the forearm. The 
triceps was involved before the biceps. The pectoralis 
major showed some loss of power. 

The deltoids, trapezii, and the muscles of the head and 
back were normal. 

The sensory loss also presented a high degree of sym- 
metry. The anaesthesia and analgesia involved, roughly 
speaking, the distribution of the ulnar, internal cutan- 
eous and lesser internal cutaneous nerves in the arm. 

On the anterior aspect of the chest the upper border of 
the anaesthetic area is indicated on either side by a line 
beginning about two inches above the axillary border and 
passing through the fourth rib in the mammary line to the 
lower end of the gladiolus. 

The accompanying diagram represents with exactness 
the distribution of the sensory loss. It is to be noted that 
while on the arms and chest the symmetry is striking, on 
the hands there is some irregularity of distribution. On the 
right side the loss of sensibility involves the palmar surface 



12 



CHRISTIAN A. HERTER.. 





^S Area of Anesthesia and Anelgesia. 



ifi/bo Area of Hyperalgesia. 



CERVICAL PARAPLEFIA. J 3 

•of the little ring and middle fingers, and of the third 
phalanx of the index finger. On the dorsal surface of the 
hand it involves only the little and ring fingers, with the 
second and third phalanges of the middle finger. The left 
hand shows loss of sensibility on the palmar aspect of the 
little and ring fingers and on the dorsal surfaces of the 
same fingers. In addition the loss involves the posterior 
surfaces of the second and third phalanges of the middle 
finger, and of the third phalanx of the index finger. 

There was a cincture pain about the lower part of the 
neck. Just above and below the clavicles the skin was 
hyperalgesic. 

Below the neck there was most pronounced myo- 
idema. Fibrillary contractions could be elicited very 
readily below the neck, by light percussion, but the 
mechanical irritability of the muscles was greatest in the 
upper extremities. 

Both deep and superficial reflexes were absent as before, 
and there was retention of urine. 

The sense of posture was lost in the lower extremity 
.and trunk. The temperature sense was not tested. When 
observed the pupils were nearly equal and of moderate size. 
Their reaction to light and during accommodation was not 
noted. The position assumed by the upper extremities is 
of interest, corresponding as it does very nearly with the 
position observed by Thorburn in cases of injury below the 
fifth cervical nerve-root. Both arms were slighly abducted, 
and the' forearms tended to assume a position of flexion and 
supination. There was no external rotation of the arm, 
and when the forearm was placed in a position of full 
extension it remained so. 

During the afternoon of the 9th the temperature rose to 
104 . The pulse continued to be fair in strength. Respira- 
tion diaphragmatic. 

On October 10th the patient's condition was not mate- 
rially changed, except that the biceps was perhaps feebler. 
During the afternoon of this day the respiration became 
embarrassed, and at 6.30 on the morning of the nth, the 
patient died from respiratory failure, having survived the 
accident about forty hours. 



j 4 CHRISTIAN A. HERTER. 

The diagnosis of the position of the upper level of the 
injury to the cord was based on the distribution of the 
motor and sensory loss. The distribution of the anaesthesia 
in the upper extremities corresponds closely with that 
attributed by Ross 2 and by Thorburn 3 to destruction of the 
eighth cervical and first dorsal segments of the cord. The 
sensory indications, therefore, pointed to the lower end of 
the seventh cervical segment as the upper limit of the 
lesion. The indications derived from the fully developed 
motor palsy placed the upper level of the considerably 
higher in the cord, for in addition to the slight weakness 
developed in the pronators, supinators, and pectoralis 
major, there was decided though not absolute loss of power 
in the biceps. 

According to Thorburn 4 , the biceps is represented in 
the fifth cervical nerve, and in Starr's 6 recent table it is 
given as derived from the fourth, fifth and sixth segments 
of the cord. Hence, the lesion causing the fully developed 
paralysis was argued to have extended at least as high as 
the sixth segment. But, when the patient was admitted, 
the muscles of the hand only were paretic, and as these are 
supposed to be represented in the eighth cervical and first 
dorsal segments the indications derived from the original 
motor and sensory loss showed a close agreement. 

The upward extension of the paralysis was so rapid and 
occurred so soon after the injury that it was not attributed 
to an ascending myelitis. Moreover, the sensory paralysis 
remained stationary while the motor loss ascended, and it 
was thought probable that the damage to the nerve ele- 
ments above the eighth cervical segment was incomplete 
and perhaps referable to pressure from bone or to haemor- 
rhage into the cord, or to both, occurring soon after the 
original damage. In view of these considerations the 
upper level of the original damage was located in the 
seventh cervical segment. 

2 On the Segmental Distribution of Sensory Disorders. Brain, Jan., 1888. 

3 Cases of Injury to the Cervical Region of the Spinal Cord. Brain, Jan., 1887. 
* Spinal Localizations as Indicated by Spinal Injuries. Brain, Oct., 1888. 

5 Syringomyelia: its Pathology and Clinical Features. Table, p. 464. Am. 
Jour. Med. Sci., May, 1888. 



CERVICAL PARAPLEGIA. 15 

The autopsy, which was conducted less than twelve 
hours after death by Dr. Thacher, revealed a dislocation 
forward of the sixth cervical vertebra upon the seventh, and 
an oblique fracture through the left superior articular 
process of the sixth cervical vertebra. The extent of the 
forward displacement of the sixth vertebra upon the 
seventh was probably not more than one-third of an inch, 
if we may judge by the latitude of movement at the 
autopsy. How much pressure was being exerted on the 
cord at the time of the autopsy, it is impossible to say, but 
there seems to have been some displacement. 

The vessels of the pia near the of level the dislocation 
were fuller than above and below, and the left anterior root 
of the eighth nerve was torn across. No other extra- 
medullary change could be detected. 

The consistence of the cord was very much diminished 
throughout the eighth segment, and the gross appearance 
of the lower end of this segment was indicative of 
extensive disintegration of the nervous elements. The 
seventh segment was also decidedly soft, though less so 
than the eighth. Above and below these segments the 
consistence of the cord seemed quite normal. At the junc- 
tion of the sixth and seventh segments the central canal 
was much distended by haemorrhage, and this central 
haemorrhage was discernible as high as the upper end of 
the sixth segment, but at this level there is a very slight 
increase only in the size of the canal. 

The ascent of the motor symptoms in this case seems 
referable either to the haemorrhage into the cord or to 
post-traumatic pressure on the seventh segment of the 
cord, causing sufficient damage to produce motor without 
sensory symptoms. If the latter mechanism be the explan- 
ation of the spread of the motor loss, it must be admitted 
that the sensory palsy is due entirely to the injury of the 
eighth segment, since the anaesthesia remained stationary. 
But it is perhaps more reasonable to suppose that both the 
seventh and eighth segments were damaged simultaneously 
by the original trauma. In this case the sensory loss 
might be referable to the injury of the seventh segment as 



1 6 CHRISTIAN A. HERTER. 

well as the eighth, and the subsequet motor paralysis could 
then be explained only on the supposition that the central 
haemorrhage and slight infiltration were adequate to damage 
the anterior horns. 

Supposing the haemorrhage in the region where the dis- 
tension of the canal is considerable, and there is some 
extravasation into the surrounding gray substance, to have 
been operative in the production of paralysis, we cannot 
refer any symptoms to a higher level than the junction of 
the sixth and fifth segments, and it is very doubtful whether 
the haemorrhage observed in the upper half of the sixth 
segment could have been a factor. 

So far, therefore, as we can draw any inferences regard- 
ing the localization of the motor and sensory functions of 
the cervical cord from a single case, these are, with one 
exception, in support of the conclusions reached by Thor- 
burn from the study of a considerable number of cases of 
injury in this region. The exception relates to the repre- 
sentation of the biceps muscle. The fifth segment of the 
cord is intact in this case, and it is questionable whether 
the changes in the upper half of the sixth segment can be 
made responsible for any motor loss. Yet the biceps was 
all but completely paralyzed on both sides. We are thus 
led to the conclusion that in this case the biceps was largely 
represented in a part of the cord at least as low as the lower 
half of the sixth cervical segment. 

The involvement of the intrinsic muscles of the hand 
before the flexors and extensors of the wrist, and of the 
triceps before the biceps, corresponds in a general way 
with the vertical arrangement of the cervical nuclei as 
tabulated by Thorburn. The pronators and supinators 
were involved before the biceps, though just when was not 
noted, and they were much less paralyzed than the biceps, 
which is supposed to have a more cephalad representation. 
If the nuclei were arranged in simple vertical series without 
horizontal differentiation or vertical overlapping, such par- 
tial immunity would probably not occur in lesions of this 
kind. 



CERVICAL PARAPLEGIA. I 7 

And upon this point we must offer a word of criticism 
upon Thorburn's valuable work, in that he seems to have 
overlooked the important horizontal differentiation which 
certainly exists, in an attempt to establish the vertical 
relationship of the nuclei. In Starr's table the extensive 
vertical representation of some of the muscle nuclei is 
taken into consideration. 

I put this case upon record, not because it presents any- 
remarkable features, but because the number of cases of 
this kind, with autopsy, is still small, and every isolated 
instance may be of some aid in the localization of future 
lesions of the cervical cord. 



A CONTRIBUTION TO THE CLINICAL STUDY OF 

SPONTANEOUS DEGENERATIVE NEURITIS 

OF THE BRACHIAL PLEXUS. 1 

By WILLIAM M. LESZYNSKY, M.D., 

Lecturer on Mental and Nervous Diseases at the New York Post-Graduate Medical School ; 
Attending Physician in the Department for Nervous Diseases at the Demilt Dispensary, etc. 

WITHIN recent years the literature relating to periph- 
eral neuritis has indeed been voluminous, particu- 
larly that pertaining to the multiple form. Hence, 
much that is definite and decided has been added to our 
knowledge of this affection, which, to-day, is universally 
recognized and firmly established. 

This paper is intended to serve as a contribution to the 
clinical study of spontaneous neuritis affecting the brachial 
plexus, and is based upon the observation of the following 
unique case : 

Michael Carney, an Irish laborer, thirty-eight years of 
age, first came under observation on the 15th of October, 
1887, complaining of pain in the /^//shoulder, of one week's 
duration. He describes the character of the pain as con- 
stant, " shooting" down the inner aspect of the arm to the 
elbow-joint, and is apprehensive in regard to the probably 
serious nature of his malady, as three years ago he suffered 
from an attack of paralysis affecting the right shoulder, 
which began in a similar manner and resulted in six weeks 
of enforced idleness. His former trouble, he believes, was 
due to " taking cold," and the cause of his present illness 
he ascribes to a thorough drenching experienced in a rain- 
storm a few days before existing symptoms began. He has 
been married seventeen years, and has four children living. 
His wife states that she has had no miscarriages, but four 
of her children died from convulsions during infancy. 
Repeated interrogation fails to elicit any antecedent history 
of traumatism, syphilis, or joint disease. He confesses 

1 Read at the Annual Meeting of the American Neurological Association, 
June, 1889. 



NEURITIS OF THE BRACHIAL PLEXUS. jg 

excessive indulgence in alcoholics, followed frequently by- 
intoxication, but has abstained from the use of liquor during 
the last two weeks. Some years ago he had occasional 
attacks of muscular rheumatism (lumbago, pleurodynia, 
etc.). Bowels are constipated and appetite is poor. 

Status Prcesens. — Well-nourished, able-bodied man, with 
a moderate degree of intelligence. 

Left Upper Extremity. — Motility unimpaired ; muscular 
resistance good; no roughening or involvement of shoulder- 
joint ; tenderness and circumscribed pain on pressure over 
lower portion of biceps ; no objective sensory disturbance. 
Dynamometer registers 80 (right, 100+). All nerves and 
muscles react well to faradism, secondary coil, slide at 
12 mm. 

Right Upper Extremity. — Deltoid is markedly atrophied. 
Muscular resistance is excellent. He has full use of the 
shoulder and arm, the loss of the deltoid being replaced by 
the compensatory development of the other shoulder mus- 
cles. The extremity is otherwise normal. The deltoid 
does not react to faradism. Galvanic current of 15 milli- 
amperes produces feeble CaCC. 

Lower extremities normal. No evidence of cardiac, pul- 
monary, or renal lesion. 

Treatment. — Abstinence from alcoholics. Blister over 
biceps. Calomel, gr. v; compound licorice powder, 3 i: at 
one dose. 

Oct. 20, 1887. Reports to-day that the calomel, etc., 
produced free purgation, and that he has been in constant 
pain, which begins in the left shoulder and extends to the 
biceps. The pain is worse at night, and he is" unable to 
sleep. The left deltoid is paralyzed, and there is some diffi- 
culty in outward rotation of humerus. No objective sensory 
disturbance. 

Electrical Reaction. 

Faradism. Galvanism. 

L. circumflex nerve, O. .O. 

L. deltoid, 12 mm., good. 5 Ma. CaCC. 

Ordered rest, blisters, and antipyrin twenty grains every 
hour for three hours, unless relief is obtained sooner. 



20 WILLIAM M. LESZYNSKY. 

Oct. 25th. Pain is paroxysmal and almost unendurable, 
darting down to the dorsum of thumb and index-finger. 
He is unable to sleep at night, and "walks the streets" 
endeavoring to obtain relief through exercise. Repeated 
doses of antipyrin proved ineffectual. 

Slight temporary alleviation was obtained by wrapping 
the arm in hot-water cloths. He states that when the right 
arm was affected, the pain was just as severe, but did not 
extend below the elbow, and was always worse at night. 
He believes the arm and hand are getting weaker, and com- 
plains of numbness below the shoulder, extending over the 
radial distribution. Dynamometer registers 65 (R., 100 +). 
There is some tenderness over the lower portion of the 
radial nerve, but no appreciable thickening. In the region 
of the cutaneous distribution of the circumflex nerve there 
is an area, 2>£ cm. wide and yyi cm. in length, where tactile, 
pain, and temperature senses are abolished. The numbness 
is greatest at this point. Temperature in mouth, 99$° F. 

Electrical Reaction. 

Farad. Galv. 

Deltoid, 12 mm., feeble. 5 Ma.CaCC, slow. 

Musculo-spiral nerve and 
muscles, 15 mm., good. 

He refuses to remain abed, saying that he is more comfort- 
able while walking about. Ordered morphia sulphate, one- 
sixth grain, and repeat if necessary ; blisters; salicylate of 
soda, twenty grains every three hours. 

Oct. 29th. Pain was relieved by one third grain of 
morphia. Slept well last night without medicine. The 
hand is weaker. Grasp with dynamometer, 38. The biceps 
and triceps exhibit well-marked fibrillary tremor. In the 
fibres, at the lower portion of these muscles, there occur 
distinct, irregular, and wave - like contractions, forming 
" myoid tumors" parallel with the course of the muscular 
fibres. These circumscribed contractions are produced by 
either voluntary or passive motion or mechanical irritation. 
There is partial wrist-drop, the extensors of the forearm 
and fingers and the supinators being paretic. There is also 



NEURITIS OF THE BRACHIAL PLEXUS. 21 

difficulty in outward rotation of the arm, indicating the 
involvement of the infraspinatus and teres minor. 

The pectoralis major and the biceps group are weak, but 
the triceps is not affected. Area of anaesthesia unchanged. 
Temperature in mouth, ioo° F. 

Nov. ist. Was comparatively comfortable until yester- 
day. Then pain began at elbow and extended over radial 
side of forearm to the thumb and index-finger, but is now 
more intense over the dorsum of thumb. Recumbency 
increases the pain, which is invariably worse at night. 
Complete paralysis of infraspinatus and teres minor (no 
outward rotation). Inward rotation of humerus good. The 
pectoralis major, stipinators and extensors of forearm are also 
paralyzed. Triceps apparently not involved, but "jerk" is 
feeble. Dynamometer, 48 ; temperature, 99 F. Discon- 
tinue salicylate of soda. To have hydrarg. bichlorid., 
gr. & t. i. d. 

Electrical Reaction. 

Farad. Galv. 

Deltoid 12 mm. feeble. 

Musculo-spiral n. 15 mm. 

Extensors, O. 5^ Ma. CaCC. feeble. 

No reaction can be obtained at " Erb's Supraclavicular 
point" on either side. 

Nov. 3d. On the night of November 1st pain was excru- 
ciating and constant, darting up and down the arm in the 
course of the musculo-spiral and radial nerves to the thumb 
and index finger. Took $ grain of morphia without relief. 
Pain began at 6 p. M., and ceased at 6 A. M. He slept well 
last night without morphia, and the pain has subsided. 
The grasp is weaker. Dynamometer 25. The triceps is 
paralyzed and "jerk" is abolished. There is a point of 
extreme tenderness on deep pressure just above the flexure 
of the elbow joint. Analgesia in the course of the radial 
distribution to the hand. Partial tactile anaesthesia, more 
marked over the dorsum of the thumb. Area of anaesthesia 
below deltoid unchanged. 



2 2 WILLIAM M. LESZYNSKY. 

Electrical Reaction. 



Faradism. 


BIGHT. LEFT. 


Musculo-spiral N., 


15 mm. fair O 


Triceps, 
Deltoid, 







Extensors, 


15 mm. fair O 


Median and Ulnar N. ) 
and Muscles, ) 


Normal. Normal. 


Galvanism. 




RIGHT. 


LEFT. 


Musculo-spiral N., 8 Ma. CaCC slow. 



Triceps, 6^-Ma.CaCO AnCC. 3fMa.CaCO AnCC D. T. 

Deltoid, 15 " CaCC feeble. 3 " CaCC> AnCCslow. 

Extensors 7 " CaCO AnCC. 3i " 

Median and Ulnar N. ) Normal Normal 
and Muscles, j 

Nov. 5th. No pain since last note. Only slight aching 
in elbow. Grasp is stronger. Dynamometer 38. General 
condition of extremity unchanged. During the last few 
days he felt occasional slight pain, accompanied by tremor 
over the right serratus magnus. 

Measurement. 

Circumference. 

RIGHT. LEFT. 

Arm, 6 in. below acromion(extremity pendent) iof in. 10^- in. 
Forearm, 4 in. below olecranon (" semi-flexed) 10^- " io|- " 

Nov. 8th. Slept well on the 5th without morphia. Pain 
returned the following night. Causalgia affecting the dor- 
sum of hand during the past week. On the 7th, had pain 
all day, mostly at the flexure of the elbow-joint, over the 
lower end of the biceps, with continued numbness in the 
course of the radial nerve. Last night suffered from severe 
pain, stabbing, shooting and darting in character. He ob- 
tained some relief from the application of hot-water cloths. 
There is a slight oedema over the dorsal aspect of hand. 

Internal rotation of humerus abolished (indicating involve- 
ment of the subscapular nerves). Dynamometer 32. Sen- 
sory disturbance, etc., same. No pupillary symptoms. 

Nov. 10. Pain has extended over the forearm. Anal- 



NEURITIS OF THE BRACHIAL PLEXUS. 23 

gesia and partial tactile anaesthesia over the radial and 
external cutaneous branches of the musculo-spiral nerve. 
The biceps is paretic. With great effort he succeeds in 
slightly flexing the forearm. Pain is aggravated by pas- 
sive extension of the forearm, owing to deep-seated inflam- 
mation, probably of the musculo-spiral nerve. Slight pres- 
sure at the flexure of the elbow produces severe pain, which 
radiates over the extensors. (I was unable to satisfactorily 
determine the existence of thickened or swollen nerve). 

Electrical Reaction. 

Farad. Galv. 

External Cutaneous N., 12 mm. 6 Ma. CaCC. 

Biceps. Group. " fair. " CaCC=AnCC. 

Nov. 19th. Did not appear since last note until to-day. 
Remained abed until yesterday as he felt weak. No pain. 
Only numbness, as usual. Slept well. Upon leaving his 
bed, the pain returned in the shoulder (stormy weather). 
Pain is paroxysmal, and was so severe last night that he was 
unable to sleep. Constant causalgia over the hand and the 
wrist-joint. When the paroxysm of pain comes on, it is 
accompanied by "weakness" in the precordial region, 
with a feeling of faintness, and then "doesn't care whether 
he dies or not." Is relieved by a full inspiration and "fix- 
ing" chest. No pupillary symptoms. Scapular muscles 
and deltoid undergoing atrophy. Biceps group weaker. 
Flexion of hand and fingers good. Oedema over the dor- 
sum of the hand increasing. Dynamometer 33. Analgesia 
over the entire course of the external cutaneous and radial 
nerves, with partial tactile anaesthesia and loss of temper- 
ature sense. 

Electrical Reaction. 

Farad. Galv. 

Musculo-spiral nerve, O O 

Triceps, O 5 Ma. CaCC> An CC slow. 

Deltoid, O 5 " AnCO CaCC feeble. 

Extensors, O 5 " CaCC> AnCC slow. 

Biceps Group, 12 mm. feeble. 

Supra and infraspinati, O 



24 WILLIAM M. LESZYNSKY. 

Median and ulnar nerves and muscles react well to 
faradism 17 mm. 

Continue hydrarg. bichlorid -^ t. i. d. 

Nov. 22d. Location and severity of pain unchanged. 
Biceps group paralyzed. Dynamometer 30. 

Measurement. Circumference of arm 10^ in. Forearm 9^- 
in. Loss, \ and 1 in. 

Electrical Resistance. ) Right upper extremity, 1700 ohms. 
Seep. 33 j Left " " 2280 

Being 580 ohms greater in the affected arm. 

Nov. 26. He was obliged to take two doses every night 
to relieve the pain, which also continues during the day. 
This morning he awoke with pain, as usual, which was 
worse in the course of the radial nerve, and affected the 
thumb and index finger. Causalgia continues. Trophic 
changes in the course of the radial distribution over the 
thumb and index finger. The skin is pale, glossy, cedema- 
tous and anaesthetic. Dynamometer 20. Atrophy of scap- 
ular muscles and extensors of forearm increasing. Anaes- 
thetic area unchanged. Extremely sensitive point over the 
pectoralis major muscle on a line three inches above the 
nipple. The muscles supplied by the median and ulnar nerves 
are not affected. 

Electrical Reaction. 

Farad. Galv. 

Extern. Cutan. N. 13^ mm. slow. 6^ Ma. CaCC=An CC. 
Biceps Group, " " " " 

Median and Ulnar Nerves (and Muscles), Normal. 

Dec. 1st. During the last three nights has been free 
from pain, which is now confined to the dorsum of the 
thumb and index-finger. Dynamometer, 22. Extreme 
tenderness over biceps and pectoralis major. 

Electrical Reaction. 

Farad. Galv. 

Mus. spiral nerve, - - O. O. 

Triceps (scap., head), - O. 6 Ma.CaCC, slow. 

" (short, head), - O. 6 Ma.AnCC>CaCC, slow. 



NEURITIS OF THE BRACHIAL PLEXUS. 25 

Extensors, - - - - O. %\ Ma.AnCC>CaCC, slow. 

Scapular muscles, - - O. 6 Ma.CaCC>AnCC, " 

Deltoid, O. 6 Ma.AnCC>CaCC, " 

Biceps group, 13-^- mm. (fair). 9 Ma.AnCC>CaCC, " 
Median and ulnar nerves and 

muscles, 14 mm., - - - 5J Ma.CaCC, normal. 

Dec. 10th. Very little pain until this 3 A. M. (raining). 
Causalgia constant. Some ability in inward rotation. No 
outward rotation. Muscular atrophy increasing. Sensory 
disturbance same. Some hyperesthesia in palm. Na 
change in motility. Dynamometer, 20. Tenderness over 
the biceps and pectoralis major unchanged. Administra- 
tion of hydrag. bichlorid., gr. -^, t. i. d., continued. 

Electrical Reaction. 

Farad. Galv. 

Muse, spiral nerve, - O. O. 

Triceps, ----- O. 10 Ma.CaCC>AnCC, slow. 

Extensors, - O. 6 l /i " " " 

Deltoid, ----- O. 10 

Dec. 17th. Tenderness over the pectoralis major and 
biceps has disappeared. Otherwise unchanged. Dyna- 
mometer, 23. 

Electrical Resistance. — Right = 5590 ohms. Left = 648a 
(dif. = 89o). 

Electrical Reaction. 

Farad. Galv. 

Muse, spiral nerve, - - O. O. 

Triceps, ----- O. 6 Ma.CaCO AnCC, slow. 

Extensors, - - - - O. " CaCC=AnCC, " 

Deltoid, ----- O. " CaCOAnCC, " 
Biceps group, 15^ mm. 

(slow), " AnCC>CaCC, " 

Median and ulnar nerves, 

13^ mm., ----- " CaCC, normal. 

Measurement. — Circumference, arm, 9^ in.; forearm, 
9% in. (loss, %. in.). 



26 WILLIAM M. LESZYNSKY. 

Dec. 29th. Some improvement in the strength of the 
biceps. Fibrillary contractions and tenderness over biceps. 
No other change. 

Electrical Resistance. — Right = 5400 ohms. Left — 6300 
(d if. + 900). 

Electrical Reaction. 

Farad. Galv. 

Muse, spiral nerve, - - O. O. 

Triceps, ----- O. 8 Ma.CaCC>AnCC, slow. 

Extensors, - - - - O. 4 " = " " 

Deltoid, ----- O. 8 

Biceps group, 14 mm. (slow). 5 " " " " 

Scapular muscles, - - O. 8 " > " " 

At his request he was sent to Bellevue Hospital. 
Feb. 7, 1888. He left the hospital to-day. Since last 
note had very little pain, which was limited to the hand. 
He has regained some power in the arm. The only per- 
ceptible improvement is in the biceps group. Area of anal- 
gesia has diminished in the district of the circumflex, but is 
still well defined. Tactile sensibility improved. No loss of 
muscular sense. Trophic changes in the hand are markedly 
diminished. Atrophy of the scapular muscles increasing. 
General health good. Sleeps well. Shoulder-joint relaxed 
and articular surfaces roughened. 

Electrical Reaction. 

Farad. Gaiv. 

Muse spiral nerve, - - - O. O. 

Triceps, - O. 8 Ma.AnCOCaCC, slow. 

Extensors, ------ O. 5 " CaCOAnCC, " 

Deltoid, O. 8 " AnCC=CaCC, " 

Biceps group, - - - 1 2)2 mm. 4*2 Ma. CaCOAnCC, " 

Feb. 9, 1888: 

Electrical Resistance. — Right — 5200 ohms. Left — 7000 
(dif.+ 1800). 

March 10th. Since last note suffered occasional noc- 
turnal paroxysmal pains below elbow-joint in radial distri- 
bution. He has been a flagman on the Long Island Rail- 
road during the last three weeks. Exercising the affected 



NEURITIS OF THE BRACHIAL PLEXUS. 2J 

arm produces swelling and pain over the wrist-joint and 
soreness over the pectoralis major. General health good. 
Has abstained (?) from the use of liquor. Atrophy of 
shoulder muscles has increased. ■No improvement in del- 
toid, triceps, or extensors of forearm. Biceps group improv- 
ing. Dynamometer (stiffer spring), L. = 27 ; R. — 100 +. 
Area of anaesthesia decidedly diminished above elbow-joint. 
No loss of muscular sense. No trophic disturbance save in 
dorsal aspect of thumb. Roughening of articular surfaces 
of shoulder-joint. 

Electrical Resistance. — R.= 4700 ohms. L. = 6300 (dif. -f- 
1600). 

Electrical Reaction. 

Farad. Galv. 

Muse, spiral nerve, - - - O. 20 Ma. produces feeble 

CaCC in triceps. 
Triceps (outer head), 15)2 mm. 

(feeble), - - 

Extensors, ------ O. 8 Ma. CaCC>AnCC. 

Measurement. — Circumference, arm, 9^ in.; forearm, 9 in. 

April 14th. Complains of sudden tremors, localized 
in spots over the arm and extending to the hand. He says 
the same thing occurred in the other hand before recovery. 
No outward rotation of humerus. Very feeble inward rota- 
tion. The only improvement in motility is in the biceps 
group. With great effort he succeeds in producing partial 
flexion of forearm. No vaso-motor disturbance. No tro- 
phic changes in hand. Tactile anaesthesia in spots in the 
course of the radial nerve only. Area of analgesia limited 
to two or three spots over the radial distribution at the 
wrist. Shoulder-joint not so rough as at last examination. 2 
Atrophy of scapular muscles unchanged. Dynamom- 
eter, 30. 

2 He was recently shown by me at a meeting of the New York Neurological 
Society (April 3, 1888), at a time when the shoulder-joint was "roughened," 
owing to paralysis of the shoulder muscles and consequent disuse of the limb. 
This led one of the members present to suppose that this condition of the joint 
may have existed prior to the development of the neuritis. 



28 WILLIAM M. LESZYNSKY. 

Electrical Resistance. — Right — 5500 ohms. Left =4330 
(dif. — 1 170). 

Electrical Reaction. 

Farad. Gaizi. 

Muse, spiral nerve, - - - O. O. 

Supra- and infraspinati, - - O. 7 Ma.CaCC, feeble. 

Deltoid, O. 7% Ma.CaCC=AnCC, slow. 

Triceps, O. 6 " " " 

Biceps group, - - - 14^ mm. 5^ " " " " 

Extensors, ------ O. 9 " «■• «. >< 

Median and ulnar nerves and 

muscles, - - - - I4>2 mm. Ncrmal. 

April 28th. Electrical Resistance. — Right = 5400 ohms. 
Left = 4500 (dif. — 900). 

June 7th. No pain during the last three months. Dy- 
namometer, 33. Roughened shoulder-joint and atrophy- 
unchanged. Slight improvement in inward rotation. No 
outward rotation. Biceps group have recovered with good 
resistance to passive motion. Supination of hand is accom- 
plished by the biceps only. No other improvement in 
motility. The dorsum of the hand is cedematous. Anaes- 
thesia is limited to one small spot over the dorsum of the 
thumb. The entire surface of the extremity is perspiring,, 
save over the radial distribution below the wrist, where the 
skin is dry. 

Measurement. — Circumference, arm, 9^ in.; forearm,. 
9>£ in. 

Electrical Reaction. 

Faradism. 
Biceps, 15 mm. 

Galvanism. 

Deltoid, 7 Ma.CaCC>AnCC, slow. 

Triceps (scap. head), - - -12 " AnCC— CaCC, ' ■ 
Triceps (short head) - - - 8 " CaCC^nCC, " 

Biceps group, 5" " " " 

Extensors, 8 " AnCC>CaCC, 



NEURITIS OF THE BRACHIAL PLEXUS. 29 

Sept. nth. In rainy weather has occasional pain and 
numbness in the hand and over the deltoid. Atrophy of 
scapular muscles, deltoid, triceps, and extensors of forearm. 
Complete paralysis of the deltoid and extensors. Partial 
paralysis of the triceps. Inward rotation good. No out- 
ward rotation. Biceps group normal. Dynamometer : 
L., 43 ; R., 100-j-. No vaso-motor changes. No sensory 
disturbance. Area of anaesthesia has disappeared. Rough- 
•ening at shoulder-joint unchanged. Elbow-joint normal. 
Complete relaxation of wrist-joint. No roughening. 

Measurement. Circumference, arm 9)2 in.; forearm, 8f 
in. 
Electrical Reaction. 

Farad. CaJv. 

Muse, cutan. nerve ) ,, ^ ^^ 

, , . r 10 mm. 4 Ma.CaCC 

and biceps group ,j ^ 

Supraspinatus, - O. 5 Ma. CaCC. (slow). 

Infraspinatus, - O. 10 " O. 

Triceps (short head, 10 mm. 7 " AnCC>CaCC. (slow). 

(scap.head), O. 10 " " " " 

Deltoid, - - - O. 7 " AnCC=CaCC. 

Extensors, - - - O. 7 " AnCC>CaCC. " 

Median and ulnar nerves and muscles normal. 

Dec. 27. Since last note he has been at work driving a 
liorse. The atrophied muscles are improving. Inward 
rotation good. Partial outward rotation and improvement 
in the action of the pectoralis major. There is a slight 
return of power in the deltoid. Has good use of the tri- 
ceps. Biceps group have remained well. There is a 
tender point over the radial nerve, producing radiation of 
pain to the tip of the thumb and index finger. 

Measurement. Circumference, arm 9J in.; forearm, 91^ in. 

Electrical Reaction. 

Farad. Galv. 

Muse, spiral N, - - O. O. 

Supraspinatus, - 10)2 mm. __._--- 

Infraspinatus, - O. 16 Ma.CaCC, (feeble). 

Deltoid, - - - iot^ mm. 10 " AnCC>CaCC (slow). 

Triceps, - - - " 10 " CaCC=AnCC. 

JBiceps group, - " ______-- 

Extensors, - - O. 20 Ma. No polar reaction ; 

only feeble reaction to 
labile cathode. 

Median and ulnar nerves and muscles normal. 



30 WILLIAM M. LESZYNSICY. 

Jan. 31, 1889. No pain since last note. After using the 
left hand and arm, numbness and fibrillary contractions 
occur over the dorsum of the hand. The motility is 
increasing in the shoulder and upper arm muscles. No 
improvement in the extensors and supinators of forearm. 

June 15. He has been steadily employed since last 
note, and the condition of the left upper extremity is much 
better. The atrophied muscles are improving. Inward 
rotation of the humerus is good. Outward rotation is 
incomplete. The deltoid muscle is weak, but its motility 
is restored. Triceps and biceps group normal. There is 
some return of voluntary power in the extensors and supi- 
nators of forearm and in the extensor communis digitorum. 
There is slight roughening of the shoulder-joint. 

Measurement. Circumference, arm 10)4 in.; forearm, o,>£ in. 

Electrical Resistance. R. = 8700 ohms ; L. = 6300 (dif. 
— 2400). 



Electrical Reaction. 

Farad. Galv. 

Infraspinatus, 1 mm. (feeble). 22^ Ma. CaCC>AnCC (feeble) 

Deltoid, - 13 mm. 8A " 

Mus. spiral N, 1 mm. (feeble). 12% " CaCC (feeble). 

Triceps, - 13 mm. _.-____--. 

Biceps group, " ---------- 

Extensors, - O. 19 Ma. AnCC>CaCC (feeble). 
Median and ulnar nerves normal. 

During the entire period of observation he was extremely 
irregular in his attendance. Many times it was necessary 
to send for him to appear for examination. He virtually 
received no systematic treatment. The only instructions 
known to have been indifferently followed at home, after 
acute symptoms had subsided, were passive motion to all 
joints, daily bathing and manipulation of the muscles, and 
keeping the limb suspended and protected from exposure. 



NEURITIS OF THE BRACHIAL PLEXUS. 
SUMMARY. 



3* 



A man, thirty-eight years of age, shortly after exposure 
to cold (without antecedent history of joint disease or 
injury), suffered from severe paroxysmal pain in the left 
shoulder, rapidly followed by paralysis of the deltoid. 
After short but varying intervals of freedom from acute 
pain, another paroxysm would occur, accompanied by addi- 
tional paralyses. These attacks, extending over a period 
of four weeks, involved all of the muscles innervated by the 
circumflex, suprascapular, subscapular, musculo-cutaneous 
and musculo-spiral nerves. There was anaesthesia in the 
domain of the circumflex, external cutaneous and radial 
nerves. Well-marked atrophy, with the reaction of degen- 
eration, existed in all of the paralyzed muscles. 

Trophic changes were present in the skin over the 
thumb and index finger. 





PARALYSES. 


Eiectncal EesisbuiLe. 


MEASUREMENTS. 






~ (TERES MINOR. 


RICHT. LETT. 


ARM FTjKIAKM 
■jtantvtBKr van Uiauta r.^< 

Hn&lt J LEFT »i .via fUmtit 






pHraunttiw 


KrrU'.'n 1100 USO Okms (f J?0 ) 






I INFRASPINATUS 












Nnr. If . C lit . J < pectoraus major 


Dk. it* tsso mm • (• «9o) 


Mtw.Ot . 


. 70£ . 9t . 






1 SUPINATORS 












\, EXTENSORS 


Dtc 1ST, UtO 6MO • C'SooJ 


itc.nT 


■ 9i . Ot . 






N«rJ? . Lifi?.] ■£ TRICEPS 


Ws:ij jz#* Tmo • (frtooj 


><■ ■ 


• 9$ . 9 . 






fSUBSCAPVURIS 
Nrli . [»?•] /TERES MAJOR 


THAW'. *ua »M * (»- 1S00J 


AwTT. 


■ 9t - Pi • 






(laxissinus dorsi 


Q\r.a'. lot iSe • t-«To] 


5tjd.lt- 


• 9i • Si . 






f BICEPS 












Krrui. Uf? J JcORACO-aRACHIAJj; 


Q$rU' ■ 54*0 %S<x> • (-»«!> 


ftcOf- 


• 9i . 9i . 






ImMUHMg mmna 


jb>v(OB tut a** ■ (-ZH*: 


jfc««rw 


. »; . s-r - 









Table A. 

The median arid ulnar nerves were not implicated. Almost 
complete recovery at the end of two years. It is well 
known that motor function is always more easily abolished 
than sensory function, and that in cases of recovery from 
damage sensation invariably returns before motion. In this 
instance, the area of anaesthesia began to diminish after 
four months. At the end of one year all disturbance of 
sensibility had disappeared. 



3 2 



WILLIAM M, LESZYNSKY. 




NEURITIS OF THE BRACHIAL PLEXUS. 33 

The return of motility took place in the following order, 
the muscles attacked last being the first to recover (see 
table). 

1st. Biceps group. 

2d. Subscapularis and teres major. 

3d. Triceps. 

4th. Supraspinatus, infraspinatus, teres minor, deltoid. 

5th. Extensors and supinators of forearm. 

THE ELECTRICAL RESISTANCE. 

In obtaining the electrical resistance in the extremity, 
the following method was adopted : A flat flannel-covered 
sheet-lead electrode, 2x4 inches, being thoroughly moist- 
ened with hot salt water, was securely attached over the 
nucha. A similar electrode, 1 x 2 inches, was firmly fast- 
ened in the palmar surface of the hand, the hands and the 
electrode having been previously soaked in the hot salt 
solution. 

A sufficient number of Leclanche elements were then 
slowly introduced in the circuit (descending current) until 
4 milliamperes were registered on the meter. The same 
process was then applied to the other arm. 

Subsequently, the amount of resistance was determined 
by means of a wire rheostat. A sufficient number of ohms 
(in place of the patient's body) were introduced in the cir- 
cuit produced by the same electromotive force used in the 
examination of the patient until the meter registered 4 
milliamperes. 

The stationary electrode at the neck was kept thoroughly 
wet. In order to produce uniform pressure in both hands, 
and to avoid unequal condensation of tissue, the electrode 
was retained in position by a band. 

As there are so many elements of error to be eliminated 
before we can succeed in obtaining an accurate measure- 
ment of the electrical resistance in the human body, I 
would only claim the measurements in this case to be 
approximately correct. 



34 WILLIAM M. LESZYNSKY. 

In all eight measurements were made, extending over a 
period of nineteen months (see table A.) Five comparative 
examinations, during the existence of acute symptoms, 
invariably revealed a condition of greater resistance in the 
affected limb. At three subsequent examinations, after the 
subsidence of all acute symptoms, the resistance was found 
markedly diminished. 

These uniform results are certainly conclusive in estab- 
lishing the fact that the electrical resistance was increased 
during the active stage of the disease, and diminished dur- 
ing convalesence. 

It will be noted that on November 22d, 1887, the resist- 
ance was R=i700 ohms, left 2280; while on June 15th, 
1889, it was 11=8700 ohms ; Left =6300. 

That such an apparent discrepancy should exist,can only 
be explained (in the last observation) on the ground of the 
probably insufficient moisture of the skin, or the difference 
in the pressure of the electrodes as compared with previous 
examinations. Despite this great difference in the resist- 
ance from time to to time, the uniformity of the compara- 
tive variations, at each measurement, is sufficiently sug- 
gestive to warrant further investigation along this line. 
These observations are merely tentative, and under 
existing circumstances cannot be considered of diagnostic 
significance. 

Before analyzing the salient features of this case, it 
would be well in this connection, to present a brief resume 
of our knowledge of the anatomy and physiology of the bra- 
chial plexus. It is beyond the scope of this paper to enter at 
length upon a discussion of this subject. 

Quite a diversity of opinion seems to exist as to the 
gross anatomy of the brachial plexus. Gray 3 states, that 
"the fifth and sixth cervicals unite near their exit from the 
spine into a common trunk ; the seventh cervical joins this 
trunk near the outer border of the middle scalenus ; the three 
nerves thus form one large single cord. The eighth cervi- 
cal and first dorsal nerves unite behind the anterior scalenus 
into a common trunk. Thus two large trunks are formed, 

3 Anatomy Descriptiye and Surgical, 1871, p. 638. 



NEURITIS OF THE BRACHIAL PLEXUS. 



35 



the upper one by the union of the fifth, sixth and seventh 
cervicals ; and the lower one by the eighth cervical and first 
dorsal. Opposite the clavicle, and sometimes in the axilla, 
each of the cords gives off a fasciculus, by the union of 
which a third trunk is formed." 

Heath, Leidy, Quain, Ellis and Flower give the same 
arrangement, while the arrangement furnished by Sappey 
Cruveilhier, Hirsehfeld, Henle, Hyrtl, Longet and Lucas 
differs mainly from the preceding in that the seventh does 
not join the common cord of the fifth and sixth, but runs 
as a separate trunk, dividing below as do the other trunks. 
(Walsh). Other writers to the number of thirty hold differ- 
ent views in regard to the formation of the plexus. 




AttA OT *KAE5THESIA 



Chart B. 

According to the researches of Walsh 4 the arrangement 
of the plexus is not so variable, as most of the variations 
can be artificially produced. As a result of his examina- 
tion of 350 plexuses, he concludes that "nearly every plex- 
us will be found to resolve itself into one and the same 
arrangement, (see chart B) and it will also be discovered 
that most of the numberless variations to be found in ana- 
tomical works are nothing but normal arrangements dis- 
torted by wrong dissections." In regard to the distribu- 
tion of the filaments composing the five primary trunks to 
* Amer. Jour. Med. Sciences, Oct. 1887. 



36 WILLIAM M. LESZYNSKY. 

the terminal branches of the plexus, the same writer makes 
the following statement, based upon the study of 74 plex- 
ures dissected after maceration in dilute nitric acid. 5 

The mtisculo-cutaneous was supplied by the fifth and 
sixth in 50 cases, in 23 by these and the seventh, and 
in one (an anomalous plexus) by a few filaments from the 
fourth and by the fifth and sixth. The median in 66 by all 
five, and in 8 by the four lower. The ulnar in 71 by the 
seventh and eighth and first dorsal, in two by the two latter, 
and in one (same anomaly as above) almost entirely by the 
seventh a few fibres being furnished by the eighth. The 
Circumflex in 63 by the fifth and sixth, in ten by the fifth, 
sixth and seventh, and in one (same anomaly) by the 
seventh and eighth. 

The musculo-spiral \vv 67 by the fifth, sixth, seventh and 
eighth. In 6 by all five, and in one (same anomaly) by the 
sixth and seventh. 

The result of Herringham's 6 dissection of the brachial 
plexus in the human foetus and in the adult differs only 
slightly from that of Walsh. He claims that "the median 
nerve is'formed by two heads, into the outer the sixth and 
seventh always enter, while the fifth does not. The inner 
is formed always by branches of the eighth and ninth, 7 
sometimes with the addition of some bundles of the seventh. 
The median then is made of the sixth, seventh, eighth and 
ninth. The sixth bundle runs down the outer side of the nerve 
from the top to the bottom. The supply of the fifth by its 
anterior branch ends therefore with the musculo-cutaneous 
nerve. The eighth and ninth usually supply the flexor 
sublimis and always the deep flexors. After the forearm 
muscles have been supplied, the remainder of the median 
which comes from under the flexor sublimis always contains 
fibres from the sixth, seventh and eighth roots and some- 
times a bundle from the ninth. The most common origin 

3 Minute dissection and maceration of the brachial plexus in dissociating liq- 
uids was done by W. Krause many years ago. Beitrage Zur Neurologie der 
oberen Extremitat, 1865. 

6 Proc. Roy. Soc. Loni. 1886 --xli- 423. 

7 He calls the first dorsal nerve the ninth spinal root. 



NEURITIS OF THE BRACHIAL PLEXUS. 37 

of the ulnar nerve is from the eighth and ninth together. 
The circumflex is derived from the fifth and sixth alone. 
The musculo-spiral is sometimes formed by all four upper 
roots, usually by the sixth, seventh and eighth alone. 

From a physiological standpoint, the experiments of 
Ferrier and Yeo 8 command attention. They found that in 
the brachial plexus in monkeys, no ulnar movement occurred 
when any of the anterior roots above the first dorsal were 
stimulated. No musculo- cutaneous movement followed stim- 
ulation of any roots below the sixth cervical ; but both 
median and musculo-spiral movement followed stimulation 
of the sixth, seventh and eighth cervical and first dorsal 
nerves. 9 

Gowers 10 expresses the opinion that we are not justified 
in transferring these facts to man, except in so far as they 
receive confirmation from human anatomy and pathology. 
Nevertheless, much has been added to our knowledge of 
the function of the brachial plexus by the study of tumors, 
such as neuromata, and surgical as well as other injuries 
affecting its branches, which to a great extent favors the 
confirmation of Ferrier's experiments. 

The clinical observations of Erb 11 have served to throw 
additional light upon the localisation of lesions in the bra- 
chial plexus. In the year 1874, he described a form of 
paralysis arising spontaneously as well as from traumatism, 
affecting simultaneously the deltoid, biceps, brachialis an- 
ticus and the supinator longus. Occasionally the supina- 
tor brevis, and at times all the muscles supplied by the 
median nerve are coincidently involved. The first-named 
group of muscles, however, are always chiefly if not exclu- 
sively affected. He believes the seat of the lesion to be at 
a point where the fibres forming the circumflex, musculo- 
cutaneous and a part of the musculo-spiral nerves lie in 
close proximity to each other. He further states that it is 

8 Proc. Roy. Soc. Lond. 1881, xxxii. 

9 Ferrier has since stated (Proc. Roy. Soc. Lond. 1883 — xxxv) that the re- 
lations he gave were all one nerve too high. I have therefore designated 
the nerves in accord with his note of correction. 

'° Dis. Nerv. Syst., Am. Ed. 1888, p. 86. 
11 Ziemssen's Cyclop. II, p. 561. 



38 WILLIAM M. LESZYNSKY. 

possible, by very careful Faradic excitation of the several 
branches of the plexus, to succeed in discovering in many 
individuals, a spot (which corresponds to about the point 
of emergence of the sixth cervical nerve between the 
scaleni) from which the deltoid, the biceps, brachialis anticus 
and the supinator longus may be thrown into common and 
very energetic contraction. 12 

He is consequently of the opinion that this form of 
paralysis has its seat in the root of the brachial plexus at 
this point. Hoedemaker 13 however, maintains that the 
lesion is situated in the cord formed by the fifth and sixth 
cervical nerves, and calls attention to the fact that these 
two nerves, owing to their superficial position in their exit 
between the scaleni muscles, are especially exposed to 
injury. 

Additional cases of Erb's paralysis have been recorded 
by Remak, 14 Bernhardt, 16 Weill, 16 Nonne, 17 Lannois, 18 Giran- 
deau, 19 and others. 

From our knowledge, based upon the foregoing anatomi- 
cal, physiological and clinical data, we are enabled to de- 
termine, with some degree of accuracy, the seat of the 
pathological process in our case. 

The distribution of the paralysis corresponds with a 
lesion limited to the anterior branches of the fifth, sixth and 
seventh cervical nerves. The escape of the ulnar nerve 
and the absence of all pupillary phenomena, are indicative 
of the preservation of the two lower roots of the plexus. 

The elaborate experimental and clinical studies of 
Klumpke 20 show that oculo-pupillary troubles occur in total 
paralysis of the brachial plexus, but only in those cases 

12 1 have repeatedly demonstrated this "supraclavicular point," which is 
one of the most interesting in electro-diagnosis. 

is Deutsch Archiv. Klin. Med. v 40, p. 62, 1887. 

« Berlin Klin. Woch. No. 9—1877. 

is Zeitsch. fur. Klin. Med., Bd. iv. 3 Heft.— 1882. 

w La Province Medicale, No. 48—1888. 

,7 Deutsch Arch. Klin. Med., V. 40, p. 62—1887. 

" Revue de Medicine, p. 988—1881. 

'» Ibid. p. 186—1884. 

80 Revue de Medicine, 1885 — v — p. 739. 



NEURITIS OF THE BRACHIAL PLEXUS. 39 

where the lower roots are involved, and arise from a lesion 
affecting a communicating branch of the first dorsal nerve. 

The independent investigation of both Herringham and 
Walsh show that the median nerve invariably received fibres 
from the sixth and seventh cervical nerves. Its escape, 
therefore, is certainly extraordinary, and can only be ac- 
counted for on the ground of its anomalous origin. 

It would be difficult to reconcile these facts upon any 
other hypothesis. 

Cases of this character must either be of very infrequent 
occurrence, or they are not reported, as no analogous 
instance can be found in medical literature. 

The nearest approach to analogy is the following history, 
reported by J. Straus. 21 A vigorous, muscular man, 33 
years of age, upon awaking one morning, without any 
antecedent history of injury, rheumatism or exposure, found 
the right hand numb and the arm seemed heavier than 
usual. Within two days the numbness had extended to 
the entire arm, with gradual increase of weakness, until 
all of the muscles of the extremity were paralyzed, save 
those innervated by the median nerve. 

A study of the sensibility confirmed these facts. Anaes- 
thesia existed in the cutaneous distribution of the circum- 
flex, internal cutaneous, musculo-spiral, ulnar and musculo- 
cutaneous nerves, while sensation was preserved in the 
entire domain of the median. The paralyzed muscles re- 
acted to faradic and galvanic irritation. 

The patient made a complete recovery at the end of 
seven weeks. The nerves regained their function in the 
following order : 

1st. Musculocutaneous (within two days.) 2. Musculo- 
spiral. 3d. Internal cutaneous. 4th. Ulnar. 5th. Cir- 
cumflex. 

The return of sensation and motility in the course of the 
musculo-spiral and the ulnar was parallel and simultaneous. 
It was only in the circumflex that the return of motion pre- 

21 " Note sur un cas de paralysie spontanee du plexus brachial (avec integnte 
du nerf median) et sur quelques localisations rarer de paralysie du plexus 
brachial." Gaz. Hebdom. , 1880, No. 16. 



4<D WILLIAM M. LESZYNSKY. 

ceded that of sensibility. He believed the case to be one 
of congestive or inflammatory origin, affecting the branches 
of the brachial plexus. He offered no explanation for the 
intact condition of the median nerve, and claimed that no 
analogous case had been reported. 

Buzzard 22 refers to a case (without history) of neuritis 
affecting certain branches of the brachial plexus and occa- 
sioning local paralysis, exquisite pains, hyperalgesia, mus- 
cular atrophy, abolished or diminished electrical excitability, 
and trophic changes in the skin. 

Althaus 23 instances the case of a girl sixteen, in whom, 
after ten days of severe pain and numbness in the right 
hand and arm, the entire extremity became completely 
paralyzed. This was accompanied by anaesthesia, trophic 
changes in the skin, and loss of faradic irritability. There 
was no atrophy. 

Diagnosis. — Rheumatic neuritis of the brachial plexus. 
Recovery from periphery to centre at the end of seven 
months. 

THE ETIOLOGY. 
The prominent factors leading to the develop- 
ment of the neuritis in my case, were alcoholism as 
the predisposing element and exposure to cold the exciting 
cause. This may or may not have been accompanied by 
over-exertion. Leyden 24 maintains that the spontaneous or 
primary form of multiple neuritis is most commonly caused 
by exposure or over-exertion, and frequently by both com- 
bined. The same may be said of the form of neuritis now 
under consideration. It is evident that these two factors 
play an important part in the development of the so-called 
idiopathic neuritis, as they do in diseases of the spinal cord. 
According to Caspari's observations, cold is one of the 
most frequent causes of neuritis in Russia, where remark- 
able temperature variations exist during many months. 
Since Magnus Huss in 1852 directed attention to a form of 
paralysis occurring in alcoholic subjects, many important 

» 2 Lond. Lancet, 1885, vii., p. 983. 

23 Med. Chir. Trans., Lond., 1871, v., 54. 

2 * Die Entzlindung der peripheren Nerven, Berlin, 1888. 



NEURITIS OF THE BRACHIAL PLEXUS. 41 

contributions to our knowledge of this matter have been 
made, so that it now is a well-known and established fact 
that the toxic effect of alcohol upon the peripheral nerves 
renders them more vulnerable to affections of an imflamma- 
tory or degenerative nature, and that frequently the nerve- 
trunks become similarly implicated. 

PROGNOSIS. 

The power of regeneration of nerve-fibres seems 
almost unlimited, the length of time required for the 
completion of the regenerative process varying from a few 
weeks to seven years or more. Poore 25 refers to a patient 
with traumatic paralysis of the brachial plexus, accom- 
panied by vaso-motor and trophic changes, who had almost 
completely recovered after four years and a half. 

In one of Trepte's 26 cases of neuritis migrans, recovery 
took place at the end of seven years. 

The probable duration and progress of the case can only 
be determined with any degree of accuracy by careful and 
repeated electrical examination. 

The electrical reactions in the nerves and muscles, as- 
pointed out by Erb, 27 are of the greatest prognostic signifi- 
cance. He says : " Under otherwise similar circumstances, 
i. e., in one and the same form and cause of disease, the 
lesion is so much more serious, the duration of the disease 
the longer, the chance of complete restitution slighter, the 
more developed and complete the De R. is, and the more 
advanced the stage in which it is found. Partial De R. is 
therefore more favorable than the complete, the later stages 
more unfavorable than the earlier. 

In the cases of brachial plexus paralysis reported by 
Remak, 28 the brachialis anticus and biceps recovered first 
and the supinator longus last. He is therefore of the opin- 
ion that this may perhaps be dependent upon the length of 
the nerves, which must be regenerated from the point of 
the lesion. 

28 Lond. Lancet, 1881, p. 495. 

26 Casuistische Beitr'age zur Lehre von der Neuritis, besonders der Neuritis 
traumatica und migrans. Inaug. Dissert., HalJe, 1886. 

27 Handbook of Electrotherapeutics, 1883, p. 86. 
»« Berlin, klin. Woch., No. 9, 1877. 



42 WILLIAM M. LESZYNSKY. 

Erlenmeyer* 9 takes exception to these views, maintain- 
ing that the time of regeneration depends upon the degree 
of the paralysis and the amount of the structural changes, 
as deduced from the character of the electrical reaction by 
which such conditions are determined. In support of this 
assertion he cites the first case of M. Bernhardt, 30 where 
recovery occurred first in the biceps and brachialis anticus, 
next in the supinator, later in the deltoid, and last in the 
supraspinatus and infraspinatus. The correctness of the 
views of Erb and Erlenmeyer is clearly demonstrable in our 
case. The biceps group, presenting partial De R., recovered 
first, while the supinator longus and the extensors of the 
forearm, exhibiting complete De R., were the last to show 
signs of improvement. 

The pathology of peripheral neuritis is so well known, 
that I have purposely refrained from its discussion. 

Whether the inflammatory process in this case was of an 
interstitial or parenchymatous character, or both combined, 
is of little or no practical importance. 

The time required for the regeneration of the nerve- 
fibres is necessarily influenced by the character and severity 
of the lesion, by the recuperative powers of the individual, 
and occasionally by treatment. Recovery sometimes occurs 
spontaneously, i. e., without the aid of therapeutic measures. 
In the present case it can be safely assumed that, after the 
acute symptoms had subsided, the patient neglected all 
further treatment. 

636 Lexington Avenue. 

29 Corresp.-Bl. d. Schweizer Aerzte, 1882, V., 12, p. 619 

30 Zeitsch. fiir ldin. Med., Bd. IV., 1882, p. 415. 



HEMORRHAGE INTO THE CEREBELLUM AND 

FOURTH VENTRICLE, AND BY EXTENSION 

INTO THE THIRD AND LATERAL 

VENTRICLES. 1 

By CHARLES K. MILLS, M. D. 

JC, aged 53, was admitted to the Nervous Wards of 
the Philadelphia Hospital about July 15th. He was 
suffering from insular sclerosis and chronic parenchy- 
matous nephritis. He had tremors in both hands, more 
marked on the left ; tremors of the tongue and twitching 
of the facial muscles, also some loss of power in both arms, 
more marked on the left side, and this extremity was also 
slightly atrophied. His left leg was weak, but he had no 
difficulty in walking. The only intention, however, at 
present, is to report the hemorrhage from which he died. 
The patient worked in the diet kitchen and was feeling well 
until two days before his death, when he began to feel 
dizzy and complained of headache. He was perfectly con- 
scious, but his symptom grew gradually worse, and in an 
hour he was completely unconscious. His face became 
cyanotic. His pulse was 72, and full. He had complete 
paralysis of the left side of the body, and on the chest on 
the left side fine muscular twitchings were observed. The 
pupils were slightly contracted and immobile. He had no 
convulsions. His temperature at the time of his seizure (one 
o'clock) was 96 ; at two o'clock it was 98. 2° ; at fifteen 
minutes after — the time of his death, it was 98. 2°. Before 
death he was very cyanotic and evidently died of respira- 
tory failure. The respirations ceasing a considerable time 
before the pulse. 

Autopsy. — The scalp was much congested with venous 
blood. The longitudinal sinus contained no clots. The 

1 Presented to the Philadelphia Pathological Society. 



44 CHARLES K. MILLS. 

dura mater was normal. No evidence of meningeal hem- 
orrhage was present, but under the pia mater covering the 
posterior and inferior portion of the cerebellum was ob- 
served a slight extravasation of blood. The vessels at the 
base presented a few atheromatous patches. On opening 
the lateral ventricles a clot was found on the left side, situ- 
ated in the anterior portion of the ventricle, but not involv- 
ing the brain substance. The fourth ventricle was filled 
with black, tarry blood. The main damage to brain tissue 
was found in the pons, crura, and cerebellum. The tissue in 
these tracts was plowed up and disorganized. The lentic- 
ular nuclei and capsules of the brain were not involved. 
The heart was hypertrophied, but there were no valvular 
lesions. The kidneys showed evidences of chronic paren- 
chymatous nephritis. The spleen was enlarged, the 
liver adherent to the diaphragm and very friable. 



'tvistopz. 



EXCEBPTS FBOM SWEDISH, DANISH, NORWEGIAN AND FINNISH JOT7BNAL8. 

By FREDERICK PETERSON, M.D. 



HYPNOTISM IN SCANDINAVIA. 

L. Bentzon describes a few cases of hypnotization em- 
ployed as a therapeutic measure ("Ugeskr. f. Lager," R. 4, 
Bd. 16, S. 579). One was a young hysterical woman, who 
had suffered for a long period from cephalalgia and pain in 
the arms, from which she was freed in one seance. Another 
was a woman, aged 63, who had endured for two years 
severe rheumatic pains. She was cured in twelve seances. 

G. Lutken ("Ugeskr. f. Lager," R. 4, Bd 16, S. 617) 
describes 13 cases treated by hypnotism as follows: (1) A 
man with hypochondriasis was cured by suggestions made 
in nine seances. (2) A woman with neuralgia of the lin- 
gual and oesophageal nerves recovered. (3) A woman with 
"morbus mentalis" got well after three seances. (4) An- 
other hypochondriac cured after three seances. (5) Chorea 
in ;i ten-year-old girl ceased after five hypnotizations. 

(6) A man was cured of stammering after ten suggestions. 

(7) A girl of eleven, with chorea and onanism, recovered 
after fifteen seances. (8) A woman with neurasthenia and 
neuralgia recovered. (9) A man much improved in mental 
state for a time, but grew worse subsequently, as the case 
proved to be paresis. (10) A case of hysteria, with enure- 
sis and pain in the legs, entirely cured after sixteen seances. 
(11) A woman of 41, with melancholia, who had twice 
attempted suicide, recovered after six seances. (12) An- 
other case of stammering, in a young man, cured. (13) 
Nervous condition following an apoplectic attack markedly 
improved under hypnotization. 

S. Hytten ("Ugeskr. f. Lager," R. 4, Bd. 16, S. 648) 
reports the use of hypnotism in a number of cases of ner- 
vous disorder. (1) Cephalalgia of many years' duration, 
in a twenty-seven-year-old woman, was made to cease for 
some months by suggestion in a single seance. (2) Hyster- 
ical paralysis in a fourteen-year-old girl was cured in a few 
seances. (3) A thirteen-year-old girl, "shy, tired of home 
and evil-tempered," was improved in six seances. (4) Hys- 
teria in a sixteen-year-old girl was cured. (5) Sciatica in 



46 PERISCOPE. 

a twenty-six-year-old woman disappeared after four seances; 
was replaced by supraorbital neuralgia, which quickly van- 
ished under suggestion. (6) Cephalalgia and rachialgia 
cured speedily. (7) Hysterical hemiplegia recovered after 
three seances. (8) Sciatica cured in another case in five 
seances. (9) Stammering in a young man easily removed. 
(10) A tooth was extracted without pain in a woman under 
suggestion. 

F. Bjornstrom has written a 222-page book (recently 
translated into English) giving a good resume of the devel- 
opment and present standing of hypnotism in the scientific 
world, intended for physicians and jurists, but also to warn 
the public in general against its misuse. The author is 
thoroughly familiar with the work of the Paris and Nancy 
schools. 

O. G. Wetterstrand (" Hygeia," 1888, S. 288, 130, 171) 
reports a large number of patients suffering from various 
disorders improved or cured by suggestive therapy. 

P. D. Koch ("Ugeskr. f. Lager, R. 4, Bd. 17, S. 10) 
shows that hypnotism will soon take its proper place in 
medical science as a therapeutical measure of great import- 
ance. Magnus Huss, of Stockholm, has written an 82-page 
book upon the dangers of hypnotism. While he recognizes 
its value as a means of treating numerous disorders, he 
brings forward facts to show that its use may in some cases 
lead to disturbance of reason, and advises that public exhi- 
bitions of hypnotic experiments should be forbidden, and 
that physicians only should be allowed to practice it, but 
under certain legal conditions, in order to prevent its use 
for criminal purposes. 

EXTIRPATION OF A CEPHALOCELE. 

Dr. C. A. Bergh (" Nor. Med. Archiv.," 2d quarter, 1888) 
describes the case of a girl baby, five weeks old, admitted 
into the Gefle Hospital in 1886, with an occipital hydro- 
cephalocele. It was an elastic pedunculated tumor, 10 cm. 
in diameter, springing from the posterior fontanelle. It 
increased in size on crying. Pressure revealed tissue of 
firmer consistence in its interior, but caused no cerebral 
symptoms. A clamp was applied, and the tumor punctured 
and removed under antiseptic precautions. A piece of 
brain the size of a hazel nut was evacuated with the serous 
fluid. The clamp remained in situ for twenty days. Com- 
plete recovery took place, but there is at present a slight 
sign of return. 



PERISCOPE. 



ON THE DIRECT HEREDITY OF INSANITY. 



47 



In the ("Hosp.-Tidende," R. 3, Bd. 5, S. 1129, 1172, 
1 190, 1220) Dr. Th. Eibe presents some interesting statistics 
with reference to this subject from the Norrejyske (Den- 
mark) asylum. Out of 3,500 patients treated here since the 
opening of the institution, there were 55 who had children 
later admitted insane. There were 19 fathers with 8 daugh- 
ters and 15 sons, and 36 mothers with 15 daughters and 24 
sons — or in all 55 ascendants and 62 descendants. 

Fifty-four of these ascendants had altogether 294 chil- 
dren. Of these children 52 died in early childhood, 91 are 
or have been insane, 1 is epileptic; and of 150 nothing 
pathological is known. With regard to the offspring of the 
descendants, the time is not yet ripe for exact statistics, as 
the figures will change in a few years. However, $j per 
cent, of the descendants are entirely childless, 35.5 per 
cent, have had children, and in 27.4 per cent, the possibility 
of having children cannot yet be excluded. The following 
table gives some information as regards prognosis : 







Descendants. 




Form of Insanity in 
Ascendants. 


Age, at 
Outbreak. 


Recovered. 


Puberty 

Psychoses. 


Periodic Forms 

Melancholia 


19.9 
21.1 

23.2 


II % 

59 " 
67 " 


89% 
76 " 
67 - 





EMOTIONAL DISTURBANCES AS A CAUSE OF DISEASE. 

Some cases of interest are cited by Dr. A. Sell ("Hosp.- 
Tidende," R. 3, Bd. 5, S. 961, 985) in an article upon this 
topic. Among them are two of apoplexy following mental 
strain ; a case of epilepsy after fright ; eclampsia in a four- 
year-old child due to a slight punishment ; a case of renal 
colic beginning immediately after receiving bad news, and 
ending with the discharge of a concrement ; and one of 
great increase of bodily temperature after extraction of a 
tooth. 

FOUR CASES OF APHASIA, WITH AUTOPSIES. 

In the "Upsala lak. forhandl." (Bd. 21, S. 380-93) S. E. 
Henschen reports in detail the following cases with illus- 
trations : 



48 PERISCOPE. 

Case I. — Amnesic aphasia and agraphia, and at th e 
beginning aphemia, in a woman aged sixty-two, with steno - 
sis aortas. She could repeat every word said to her, but 
spontaneous expression of thought was completely lost. 
Would use incorrect words. Duration of aphasia eleven 
days. Death two years later. Autopsy : Softening in a 
part of F 3 and F 2 and neighboring O. 

Case II. — Word blindness, amnesic aphasia, and in the 
beginning ataxic aphasia, in a laborer, aged fifty-five. 
Apoplexy, right hemiplegia. Could see letters, but make 
no word of them. Understood what was said to him. Could 
not read or write. Death in about a month. Autopsy : 
Softening in the left gyrus angularis extending downwards 
into the depth of the fossa Sylvii. 

Case III. — Word blindness with amnesic aphasia, and 
partial word deafness, in a woman aged fifty-seven. Apo- 
plexy without paralysis. Autopsy : Softening in the pos- 
terior part of the first temporal convolution, extending over 
the posterior part of the second also and to the gyrus 
angularis. 

CASE IV. — Word blindness, motor aphasia and right 
hemiplegia in a man aged twenty-nine. Autopsy : Exten- 
sive disorganization of left hemisphere about F 3 , foot of F 2 , 
lower part of both central convolution, P 2 , a part of P 1 , T 1 
and T 2 . 

HEMIATROPHY OF THE TONGUE OF BULBAR ORIGIN. 

S. E. Henschen ("Upsala lak. forhandl.," Bd. 21, S. 347) 
collects eight known cases and adds one of his own, which 
is as follows : 

At nine years of age the boy had scarlet fever, and at 
fifteen a fall from a horse. Although the fall did not hurt 
his head or cause him to lose consciousness, his left arm 
was weak subsequently, and some contracture of the fingers 
of the left hand followed. Deformity in the tongue had 
never been noticed until he entered a hospital for uraemia 
and pulmonary oedema. There was very marked atrophy 
of the right half of the tongue. Left abductor paresis of 
the larynx. Left hand claw-like. No symptom of tabes. 
Right soft palate atrophied. The author regarded the 
atrophies as a result of scarlet fever. The nuclei affected 
were some of those of the hypoglossus, vagus, accessorius 
and facialis. He would have considered the main en griffe 
a part of the process had not the patient declared this to be 
the result of trauma. 






PERISCOPE. 49 

A CASE OF LANDRY'S PARALYSIS, WITH RECOVERY. 

L. Lorentzen describes the following case in the 
"Ugeskr. f. Lager" (R. 4, Bd. 17, S. 597) : A woman, aged 
thirty-six, after exposure to cold, noticed a paresis in her 
legs, which grew worse rapidly. Nine days later there was 
complete paralysis of both legs and almost complete of 
both arms and of the muscles of the neck. She could make 
weak movements of the fingers only, and move the head 
slightly from side to side. Later there was marked paresis 
of the lips and of the abducens of both eyes, but none of the 
tongue, palate or pharynx. Respiration, defecation and 
micturition normal. The face was somewhat congested, 
temperature raised a little the first five days, pulse accele- 
rated, but never above 92. There was no splenic enlarge- 
ment, no albuminuria. Fundus oculi normal. The deep 
reflexes were absent, the skin reflexes very weak. Paralysis 
flaccid. Reaction of muscles to both currents retained. 
There was no anaesthesia and no pain or tenderness. Im- 
provement took place gradually, first in the arms, lips and 
trunk muscles, last in the eye muscles and legs. Complete 
recovery in three months. There was never any atrophy 
of the muscles. The author considered the diagnosis to lie 
between acute poliomyelitis anterior, acute multiple neuritis 
and Landry's paralysis. He believed the case to belong in 
the latter category, and localized the pathological process 
in the spinal cord and medulla oblongata. 

RHEUMATIC TIC CONVULSIF WITH THICKENING OF THE 
TRUNK OF THE FACIAL NERVE. 

S. E. Henschen (" L T psala lakarefor. forhandl.," Bd. 23, 
S. 219) relates the case of a twenty-seven-year-old teacher 
who had suffered a number of years from tic convulsif on 
the left side of the face after exposure to cold. The trunk 
of the facial nerve and some branches of the trigeminus 
were found to be tender and considerably thickened. After 
six weeks' massage the swelling and tenderness disappeared, 
and she was discharged recovered. The author believes 
that an inflammatory process in the sheath of the facial 
nerve was produced by cold, and that this was the cause of 
the convulsif tic. He looks upon migraine seizures as due 
to thickening in branches of the trigeminus, a perineuritis, 
and has corroborated this frequently since his first expres- 
sion of this opinion in 1881. 



5o 



PERISCOPE. 



THE PATHOLOGY OF ACUTE POLIOMYELITIS ANTERIOR. 

J. Rissler reports ("Nord. Med. Archiv.," Vol. XX., 4th 
quarter) the results of his study of the material from five 
cases. Three died in the first week of the disease, one 
after seven weeks, and one after eleven years. His inves- 
tigations corroborate the observations of others and the 
general opinion held as to the pathological anatomy of the 
disease. The inflammatory process was rigorously limited 
to the anterior horns, and the degenerative changes pro- 
duced in the ganglion cells were very characteristic. The 
contribution is from the laboratory of the nerve clinic of 
Prof. Wising in Stockholm, and its being written in German, 
places the 58-page paper within the reach of those inter- 
ested. Some remarkably beautiful plates are published 
with the article. 

PSEUDO-HYPERTROPHIC MUSCULAR ATROPHY IN TWO 
BROTHERS. 

J. W. Runeberg and E. A. Homen describe these cases 
in the proceedings of the "Finnish Medical Society" (Bd. 
29, No. 4, S. 212 and 213). Mother feeble-minded, father 
alcoholic, maternal uncle insane. One boy, aged eight, 
began at five to exhibit an uncertain and wobbling gait, 
the legs gradually becoming large, and the upper part of the 
body emaciating. Upon his entrance to the clinic, the 
muscles everywhere, except on the legs, flaccid and atro- 
phied ; very great lardosis ; thigh and calf muscles very 
large and prominent and firm in consistence ; intelligence 
feebly developed. 

The other boy, aged fourteen, also began at about the 
age of five to present unevenness of gait. He grew rapidly 
worse, so that for two years past he has been confined to 
bed. On entering the hospital he could not raise himself 
in bed. Muscles of upper part of body greatly atroph'ed, 
and calves only are voluminous and firm. The reaction of 
muscles to galvanic and faradic currents greatly diminished. 
Feeble minded. 

TREATMENT OF PERIODICAL DRUNKENNESS WITH 
STRYCHNINE SALTS. 

Max Buch gives an account of the successful experiences 
of himself and others in the cure of inebriety by this means 
("Finska lak. handl.," Bd. 29, No. 4, S. 204). He follows 
Popoff, Tolwinsky, Parzewsky, and Sawatyky in undertak- 
ing this method. Either the sulphate or nitrate of strych- 
nine may be employed, in solution or pills, or by hypodermic 
injection. The doses used are .001-003, once to thrice 
daily. 



PERISCOPE. 

EXCEEPT8 FKOM ITALIAN JOUBXALS. 

By GRACE PECKHAM, il. D. 



RESULTS OBTAINED BY SUSPENSION IN CASES OF TABES. 

(" Rivista Sperimentale di Freniatria e di Medicina 
Legale," 1889.) 

Suspension was practised a number of times in eleven 
cases, with the result that, with the exception ol two cases, 
there was an improvement in walking, but no alleviation of 
the pains. The results of the experiments neither contra- 
dicted nor affirmed those ot Salpetriere. 

CONCERNING MOTOR HALLUCINATION. 

(Notes by Prof. A. Tamburini, " Rivista Sperimentale di 
Freniatria e di Medicina Legale," vol. xv., fasc. iv., p. 444.) 

The writer reports the case of a peasant of low intelli- 
gence, twenty-seven years old, who at fifteen, after a grave 
affection, had an attack of melancholy, in which she had a 
hallucination of hearing a voice which said to her, " Lost 
forever," which lasted about four months. In March, 1888, 
after she had been married a short time, she had a return of 
melancholia, was apathetic and sleepless ; she had also 
some dysmenorrhea and leucorrhoea. She said that "words 
formed themselves in her mouth." When she attempted to 
take food, she felt come into her mouth the words, " Thou 
couldst eat a serpent," " Thou couldst swallow a live toad." 
When praying there would be maledictions against divinity 
and obscene expressions. Later she was obliged to repeat 
in a high voice the words which formed themselves con- 
tinually in her mouth, which she must repeat in a rapid 
manner. She also had clonic spasms. There was a light 
rhythmical movement in the tongue and in its tip, accom- 
panied by a sound which could be heard when her mouth 
was closed. Her lips were motionless. There were also 
clonic spasms in single groups of muscular fibres, especially 
those used in articulation. 

The psychical examination was imperfect, owing to the 
limited intelligence of the patient. The physical examina- 
tion showed that the cranio-facial type tended to the cuti- 
noid ; forehead low ; nose flat ; intermittent asymmetry of 
the pupil ; oscillatory movement of various muscles of the 
face; sensibility normal, and symmetrical for both sides of 
the body ; organic functions normal. 

The author, after reviewing the case and the literature 
of the subject, including the various theories, comes to the 
following conclusions : 



5 2 MISCELLANY. 

1. That besides the purely sensory hallucinations, it is 
of interest to distinguish the motor hallucination, which dis- 
plays itself more especially in the movements relating to 
speech, but may also show itself in any part of the body 
capable of movement. 

2. That the seat of this last kind of hallucination ought 
to be located in the cerebral cortex. 

3. That according to trie degree of irritation of these 
same centres, there would be simple hallucination of move- 
ment or the transformation of this into an inconvertible im- 
pulse, even to a relative convulsion. 

4. That, moreover, taking specially into account the 
physiological and clinical data, in which is admitted the 
miexd sensory-motor nature of all the cortical centres, 
there is, in every hallucination a part proportioned to that 
belonging to each centre, so much of the sensory image as 
is appropriate to the motor. 



£*lisccUang. 



THE SOLVENT PROPERTIES OF BUFFALO LITHIA WATER. 

The " Virginia Medical Monthly," Dec, 1889, contains 
a paper by Dr. John Herbert Claiborne, of Petersburg, Va., 
in which an account is given of a case of severe lithiasis 
treated effectually by large doses of lithia water. The 
patient had a violent attack of nephritic colic in August 
last, passing gravel from the kidney into the bladder, where 
it remained several weeks, setting up severe inflammation 
and causing distressing symptoms, and finally forming a 
calculus. Crushing the stone or performing lithotomy was 
considered inexpedient on account of the intense inflamma- 
tion. The patient was put to bed, the diet restricted to 
milk, and opium suppositories administered in sufficient 
doses to relieve tenesmus and pain. The patient drank 
from half a gallon to a gallon of Buffalo lithia water, and in 
about ten days commenced to pass in surprising quantities 
what appeared to be the detritus of the gravel. Urine that 
had been deposited on a clean board, left, in evaporating, 
about a drachm or two of sediment like whitewash, contain- 
ing phosphates, urates, etc. This continued for a week. 
Then the bladder was washed out with a warm solution of 
boracic acid, and the patient, at the time of writing, reported 
himself well and free for the first time from all kidney or 



MISCELLANY. 53 

bladder trouble. An editorial in the same journal speaks 
of the attention Dr. Claiborne's paper must necessarily 
attract, on account of his reputation as a close observer and 
a cautious writer. 

Prof. George B. Fowler, in the " Reference Handbook 
of Medical Sciences" (vol. i., p. 718), pronounces himself as 
favoring the use of this lithia water in lithiasis, etc. So also 
does Dr. H. B. Millard, in his standard "Treatise on Bright's 
Disease." The Virginia waters are more than respectable 
rivals of the celebrated Vichy Spring. L. F. B. 

THE JOHNS HOPKINS HOSPITAL BULLETIN. 

The trustees of the Johns Hopkins Hospital have author- 
ized the issue of a monthly publication with the above title, 
to contain announcements of courses of lectures, pro- 
grammes of clinical and pathological study, details of 
hospital and dispensary practice, abstracts of papers read 
and other proceedings of the Medical Society of the hospi- 
tal, and all other matters of general interest in connection 
with the hospital work. Nine numbers will be issued 
annually. 

The first — December, 1889 — is at hand, and contains 
readable and instructive papers on the following subjects : 
A Brief Account of the Johns Hopkins Hospital ; Opening 
of the Nurses' Home and Training-School ; Preliminary 
Report of Investigations concerning the Causation of Hog- 
Cholera, by William H. Welch, M.D. ; On the Value of 
Laveran's Organisms in the Diagnosis of Malaria, by Wil- 
liam Osier, M.D. 

Among various attractive announcements, the following 
is of especial interest to students of psychiatry : "A course 
of five didactic lectures for graduates in medicine will be 
given by Dr. Hurd, superintendent of the hospital and pro- 
fessor of psychiatry, Johns Hopkins University, during 
January and February, upon the Genesis of Delusions, the 
Insanities of Childhood, Pubescent, Adolescent, Climateric, 
and Senile Insanities, Insanities from Constitutional Disease, 
and Clinical Groupings of Insanity." L. F. B. 

NOTE UPON THE PAPER, "THE RELATION OF THE THALA- 
MUS," ETC., IN THE NUMBER FOR JULY, 1 889. 

Owing to the failure of proof to reach the author, cer- 
tain corrections and additions should be made. 

Page 436. After the title insert : Presented at the 
Washington Meeting of the American Neurological Associ- 
ation, August, 1888. 



54 MISCELLANY. 

Page 437, about middle, for striato-thalamic groove, read 
tenial sulcus ; for plexal groove, read fimbrial sulcus. 

Page 438, 8th line from top, for Mihalkorics, read 
Mihalkovics ; 18th line, for Gegenbauer, read Gegenbaur ; 
20th line, for Vicgdazyr read Vicq d'Asyr ; 9th line from 
bottom, after deny insert that ; 4th line from bottom, for or 
read of; 3d line from bottom, the semicolon should be 
replaced by a colon and dash, : — . 

P. 440, 2d line, for mammels read' mammals. 

P. 441, 9th line from top, dele the comma after and ; 2d 
line, in place of my paper 36, read the N. Y. Medical Journal, 
April 26, 1884. ; loth line from top, for all, read most ; nth 
line from top, dele the words from mammals to close of sen- 
tence. 

P. 442, 13th line from bottom, insert a comma after 
paracceles ; 8th line from bottom, omit that ; 12th line from 
bottom, for all, read most ; nth line from bottom, dele the 
words, excepting the anthropoids. 

P. 443, 7th line from bottom, for diocoelian read diacoelian ; 
5th from bottom, for lateral r cad laterad. 

A corrected reprint will be sent upon application to the 
author. At the meeting of the Association of American 
Anatomists, in Philadelphia, Dec. 26, 1889, the subject was 
considered with special reference to the condition of the 
parts in the anthropoid apes, and the term paratela pro- 
posed for the fusiform zone of membranous parietes that, 
in the human adult, intervenes between the divaricated fim- 
bria and tenia and is sometimes attached closely to the 
dorsal surface of the thalamus ; Schwalbe calls it lamina 
chorioidea lateralis. Figures such as are suggested on p. 44.3 
are given in the last volume of Wood's " Reference Hand- 
book of the Medical Sciences," Figs. 4750, 4751. 

B. G. Wilder. 



^acietrj gteports. 



PHILADELPHIA NEUROLOGICAL SOCIETY. 

Stated Meeting, October 28, 1889. 

The Vice-President, Dr. Wharton Sinkler, in the Chair. 

A CASE OF HEMIANOPSIA WITH DYSLEXIA | ALSO JACK- 
SONIAN EPILEPSY. 

By Chas. K. Mills, M.D., and G. E. de Schweinitz, M.D. 

J. H. C, aged forty-five, white, collector, was sent to 
Dr. Mills by Dr. J. H. Packard, of Philadelphia. He 
had no history of syphilis, but about six years ago had two 
attacks of acute rheumatism. He had suffered with head- 
ache since boyhood. Some failing sight and dizziness had 
come on during the summer of 1888. He has headache at 
time, but not steadily ; sometimes he goes to bed with it 
and gets up without it. 

December 17, 1888, while walking in the street, his left 
hand and arm felt queer, and became affected with spasm, 
shaking so that he had to hold it with the other hand. He 
got into a car, the arm twitching and jerking, and before he 
reached home had convulsions with unconsciousness. He 
was taken home, and found, when he came to his senses, 
that he was partially paralyzed in the right arm and leg, 
the loss of power being most marked in the leg. He thinks 
he has no paralysis of the face, but his speech was much 
affected for two or three weeks. He soon recovered from 
the paresis, but had a second " fit" in about three months, 
having three spasms within an hour. He does not know 
how these spasms began, how they spread, and how long 
they continued. Since then he has had no seizures, and 
this series of attacks did not leave him paralyzed or his 
speech affected ; but he discovered that he could not see 
half of objects to his right. 

He reads in a very peculiar way — slowly, and pronoun- 
cing each word separately, or at the most two or three 
words ; he seems to have difficulty in seeing the word ; he 
says that he sees it plainly, but that he soon gets mixed 
and confused. Although he sees the words, it takes 
him a long time to form the idea of them. Sometimes 



56 SOCIETY REPORTS. 

he can scarcely make out words. In his own way he can 
go on for a short time reading, and then his brain seems to 
exhaust; he gets confused. Occasionally, when walking 
in the street, he imagines he sees something that does 
not exist — always to the right. Hearing and touch are 
normal. 

The following notes, by Dr. de Schweintz, describe his. 
ocular condition : 

In the right eye the sharpness of sight was equivalent to 
-f of normal ; in the left eye, f of normal. This deficiency 
in visual acuity was probably due to the presence of mixed 
astigmatism. In the right eye the optic disc was a vertical 
oval, bounded at its outer margin by a black line, its sur- 
face a little woolly, and all the capillaries injected ; the 
edges of the disc, however, were not obscured. In the left 
eye the disc was distinctly grayer in color, its hue being 
manifest through a superficial injection of the suriace capil- 
laries. The temporal half of the disc was unobscured ; the 
nasal edges slightly blurred. In neither eye was the disc 
swollen, nor were there any splotches nor haemorrhages in 
the retina. The pupils of both eyes were equal in size, and 
reacted normally to the changes of light and shade, con- 
vergence and accommodation. The hemiopic pupillary 
inaction (Wernicke's symptom) was not present in either 
eye. There was complete right lateral hemianopsia, the 
field of the left side being proportionately much smaller 
than its fellow on the right, and both the preserved fields 
exhibiting concentric contraction. The dividing-line on 
the left side almost cut the fixing point. That on the right 
side, on the horizontal meridian, touched the fixing point, 
while above and below this it spread five degrees from the 
centre, making a curious reentering angle at this point. 

Dr. Mills said : This seems to be an important case in 
the study of localization. It presents four or five important 
features : (i) The Jacksonian spasm confined chiefly to the 
left hand and arm, in the first attack at least beginning and 
continuing for some time before consciousness was lost. 

(2) Temporary paresis of the arm and leg upon this side. 

(3) Right homonymous lateral hemianopsia. (4) Absence 
of Wernicke's symptom. (5) Dyslexia. The hemianopsia 
seems without doubt to be cerebral in character, Wernicke's 
symptom and choked discs being absent. The lesion is 
back of the primary optic centres, and is therefore either in 
the optic radiations, the cuneus, or the lateral convexity of 
the occipital lobes. As between these the lesion is probably 
in part in the optic radiations. The optic radiations coming 



SOCIETY REPORTS. 57 

from the primary optic centres curve around the posterior 
horn to the occipital convolutions. In the acts of reading 
and writing there is of course a conveyance of impressions 
by a commisural channel between the visual areas of the 
cortex and the arm and leg centres. We are greatly lack- 
ing in a knowledge of the coarse anatomical relations 
between these commisural fibres, the horns of the ven- 
tricles, the lateral ventricles, and the cortex. There seems 
to be a position where the commisural fibres intermingle 
with or abut against the optic radiations. This may be per- 
haps where the parietal, temporal and occipital lobes come 
together around the roof of the ventricle. The lesion is in 
the centrum ovale at a point near what might be called the 
parieto-occipito-temporal junction. Itis well back over the 
roof of the ventricle, perhaps above the place where the 
lateral ventricle joins the posterior horn. 

Dr. DE SCHWEIXITZ said that he went further than the 
mere ocular examination, and looked into the manner of 
reading and writing. This man could read two or three 
words and then threw away the paper with a look of dis- 
gust. Again he would pick up the paper, and, after reading 
a word or two, throw it down. The same thing occurred 
when he attempted to write. He wrote a few words, and 
then his hand failed to inscribe further letters, while his 
face gave evidence of chagrin at the abortive attempt. The 
points in the ocular examination were absence of optic 
neuritis, the presence of right lateral hemianopsia, unassisted 
with Wernicke's pupillary reaction. He did not wish to be 
understood as saying there was no disease of the optic 
nerves, but there was no coarse lesion like choked discs — 
that the nerves were gray, but not in a state of neuritis. 
The optic nerves were certainly not healthy, or the pre- 
served fields would not be contracted. 

In the cases reported by Berlin, six in number, and one 
by Nieden, post-mortems were made in several, and the 
lesion was found in the white matter near Broca's convolu- 
tion. I have not at hand the original paper, but the follow- 
ing resume appears in Swanzy's " Handbook of Ophthal- 
mology : " "Dyslexia consists in a want of power on the 
patient's part to read more than a few — four or five — words 
consecutively, either aloud or to himself. * * * Although 
in most cases the dyslexia disappeared in the course ot a 
few weeks, yet other symptoms soon followed its first onset, 
such as headache, giddiness, aphasia, hemianopsia, paral- 
ysis of the tongue, hemiansesthesia, hemiplegia,'' etc. 

Dr. H. C. Wood : The objection to this theory is that 



5 8 SOCIE TY REPOR TS. 

one of the most important symptoms is omitted in making 
up the theory, that is, the contraction of the fields of vision. 
I do not see how it is possible to have lateral hemianopsia 
with contraction of the field, with the optic nerves healthy 
and yet not have a lesion of the cuneus or the cuneal region 
of both sides. 

There is one point that we forget in the discussion of 
these cases, and that is, that we do not know whether the 
symptoms presented coexisted in the beginning, or whether 
some are primary and some secondary. Dr. de Schweinitz 
will recall a case of tumor of the temporal lobe, which we 
studied together, in which we had all the symptoms de- 
scribed to-night but the dyslexia. If we suppose a tumor 
a little more forward and higher up, encroaching upon the 
Broca region and interfering with the posterior cerebral 
artery, and considered that the hemianopsia is due to optic 
neuritis, we will have a possible explanation of the present 
case. 

EXHIBITION OF A CHINESE BRAIN. 

By Dr. James Hendrie Lloyd. 

The study of the comparative morphology of the brains 
of the various human races is of more interest to the anato- 
mist and evolutionist than to the clinical neurologist or the 
practical alienist. I present this brain to demonstrate the 
truth of this statement. It does not exhibit any very marked 
differences from brains of the Caucasian and other races. 
The description of such brains pertains entirely to pure and 
abstract science, and I think is of very little practical im- 
portance. 

From the way in which Chinese brains have sometimes 
been regarded, the impression seems to be that the Chinese 
are an inferior race and that in them we have to look for 
evidences of low type. I think that is illogical and without 
foundation of fact or historic evidences. The Chinese are 
not a low race of men in any sense. The Chinese stock is 
different, historically and ethnologically, from the Caucasian 
stock. It has gone on in its own line of development, and 
may have produced some slight differences in the architec- 
ture of the brain which might appeal to the eye of those 
expert in examining the morphology of the brain ; but 
such differences are not necessarily evidences of inferi- 
ority. 

We must remember that there are different kinds of 
Chinese, just as there are different kinds of Americans. 



SOCIETY REPORTS. 59 

I have no doubt that some Chinese have worse-developed 
brains than others. This brain was removed from such a 
Chinaman as we frequently see in this country, a poor, 
miserably developed little Mongolian, who died of tuber- 
cular meningitis, under my care, in the Philadelphia 
Hospital. 

There is no doubt that in this particular Chinese brain 
there is a certain simplicity of structure and absence of rich- 
ness of convolutional development. In other words, the 
brain looks almost like some of the schematic drawings seen 
in books exhibiting the primary Assures. There is also in 
the occipito-parietal fissure what has been shown to be of 
rather a Simian type, that is, the external pli du passage, 
or bridging convolution, which in a well-developed brain 
comes to the surface, forming a well-rounded convolution, 
is in this hemisphere quite distinctly below the surface. 
This is perhaps the strongest evidence of this brain being 
below ordinary development. Besides this there is nothing 
to warrant the assertion that this is a low-type brain. 

General inspection of the surface of both hemispheres 
shows a simplicity in the arrangement of the fissures and 
convolutions. There are some slight differences between 
the two hemispheres ; for instance, the right Sylvian 
fissure is much shorter than the left. Another notable 
feature (proving perhaps a rather unusual tendency to a 
confluence of fissures) is the fact that the right first tem- 
poral fissure is confluent with the anterior portion of the 
inter-parietal; hence the angular gyrus (about which as a 
centre of vision so much was formerly written) is not well 
marked in the right hemisphere. Any other differences 
which I have noted in this brain are entirely of minor im- 
portance, except perhaps the following : 

In the right hemisphere, as already stated, the superior 
external pit de passage (the convolution uniting the parietal 
with the occipital lobe) is small, narrow, and distinctly 
depressed below the surface ; while in the left hemisphere 
it is well developed and up to the surface. The imperfect 
development of this convolution is regarded by some as an 
evidence of low type. When below the surface, it permits 
the division of the parietal from the occipital lobe to be 
much more clearly seen than is usual in the more highly 
developed human brain. It is a condition, I believe, not 
uncommon in the Simian brain. 

Dr. Chas. K. MILLS. — While these studies of brains may 
at present be useless from a medico-legal standpoint, yet 



60 SOCIETY REPORTS. 

the fact is that in low-type brains, whether Chinese or Cau- 
casian, there is a great simplicity of convolutions and fissures 
with certain special peculiarities. This is also seen in crimi- 
nal and imbecile brains. These facts show that this is fun- 
damentally a correct method of study. It is, however, not 
the only method, and is to be used in connection with other 
methods, as microscopical and pathological. In order to 
reach positive conclusions, we must study a large number 
of brains, both from the lower classes and from the higher 
classes. 

Dr. J. Madison Taylor said that in forming an opinion 
as to facial peculiarities from examination of the brain, and 
especially among the older Oriental peoples, it ir needful to 
take into careful consideration class distinctions. These 
among the Chinese are drawn into the sharpest lines. 
Development of special types along these lines, running as 
they do for centuries, is inevitable. How this may be mani- 
fested by brain-shapes we can only learn by comparing 
many of one class with many of another. So far we have 
only the lowest offscouring among us of the Chinese repre- 
sentatives of the droppings of all classes. Among these we 
may look with small hope for aught but low types. On the 
Pacific slope a few of the best upper classes — the artisans 
and merchants — are seen. Here can only be had the brains 
of the pariahs, and even these bred in sin till the resultant 
is obviously unlovely. 

Dr. James Hendrie Lloyd. — As I have said, these 
studies are of importance to the comparative anatomist and 
the evolutionist, but they are of little clinical interest, of no 
practical value to the alienist, and devoid of medico-legal 
importance. It is nothing but an assumption to say that 
these studies are made upon a low-type race. I do not 
think, because there are social castes, that the lowest caste 
has a different type of brain from the others. Caste is a 
matter entirely of social development, and has nothing to 
do with such an occult matter as the size and shape of the 
cerebral convolutions. It is notorious that examples of 
idiocy and low-type brains are common among the higher 
classes in countries in which class distinctions are most 
recognized, and, on the other hand, that the best-developed 
brains often spring from the so-called common people. 
The infusion of the blood of the people is all that saves 
many privileged classes from sinking into a very low type 
indeed. 



SOCIETY REPORTS. 6 1 

Stated Meeting, November 2j, i88g. 
Vice-President, Dr. WHARTON SlXKLER, in the Chair. 

Two recent specimens were presented by Dr. Charles 
K. Mills : 

I. — HEMORRHAGE BENEATH THE SCALP, AND CEREBRAL 
AND CEREBELLAR HEMORRHAGES IN A CASE OF 
ALLEGED TRAUMATISM. 

This specimen was from a woman about sixty years of 
age. of whom it was alleged that she was struck on the head 
by her husband, both she and her husband being at the 
time drunk. 

The following are the notes taken of the condition of the 
patient after admission to the hospital : 

She was admitted on November 22d, at 10.30, in an un- 
conscious condition. She lies upon her back, eyes closed ; 
perfectly quiet, and does not move unless disturbed. On 
examination an area of discoloration is found on the left 
cheek, extending to the eye on the same side. The left 
eye is swollen and blackened, and the whole of the right 
side of the face seems slightly swollen. On the right side 
of her head, about the posterior superior angle of the parie- 
tal bone, is an area about two inches in diameter, nearly 
circular in form, which feels like a boggy mass underneath 
the skin. Xo fracture of the skull is apparent. Both ocular 
conjunctivae are chemosed, especially on the right. Her 
head deviates to the left side, and the left eye is turned to 
the left and moderately dilated ; the pupil is immobile. 
The right eye is straight, the pupil is very small and immo- 
bile. She has no marked paralysis of the face ; the left 
cheek is puffed, and is drawn in and out on expiration and 
inspiration. The left arm is paretic — not completely paral- 
yzed ; she seems to have slight power of moving this arm, 
but only does so when irritated. The forearm is always 
carried at a right angle with the arm ; the wrist and fingers 
are partially flexed. The right arm is considerably more 
rigid than the left ; the forearm is at an obtuse angle to the 
arm ; the wrist and fingers nearly extended. Both hands 
are cold. The left lower extremity is fully extended, and 
the right leg is partially flexed at the knee ; the foot is 
extended and inverted, and partial loss of power is undoubt- 
edly present in both extremities. The feet are cold. The 
left knee-jerk is diminished, the right normal. Sensation 



62 



SOCIETY REPORTS. 



is present in the face, oody, and lower extremities, but 
seems to be abolished in the upper extremities. Her breath- 
ing is stertorous and at times of the Cheyne-Stokes type. 
She swallows with difficulty, and passes her faeces and urine 
involuntarily. Her pulse is regular, of moderate volume. 
The heart and lungs appear to be normal. Examination of 
the urine gives negative results. 

The following is a record of temperature, pulse, and 
respiration : 



Temperature, 97 ; 
97.2 
97-4° 
97-i° 
984 
99. 1 ° 



pulse, 78; respiration, 21 — on admission. 
72; " 24 — 1 A. M. 

64; " 24—4 P. M. 

90; " 18 — noon. 

100; " 24 — 7 p. M. 

64; " 20 — 10.30 P. M. 



November .?./, i88g. — This morning the patient seemed to 
be rather improved ; her breathing was less stertorous in 
character, more regular, and her pulse quite good. She is 
still unconscious. Motor and sensory disturbance almost 
the same as yesterday, except that sensation seems to be 
present in the upper extremities but abolished in the lower. 
When pressure or percussion is made over the injury to the 
head the patient moves her arm on the right ; this may be 
due to pain. The left pupil is not quite so much dilated, 
and the right one seems a trifle larger ; both are im- 
mobile. 

November 24, 1889. — In the evening she relapsed into 
complete unconsciousness, her breathing became more 
labored, her pulse rapid and weak; there were trachial rales, 
and the patient died at 5.30 P. M. 



Temperature, 98 4 ; pulse, 85 

98.4 ; •• 76 

98.2 ; " 80 

98. 2°; " IOO 

" 99-6°; " 104 



respiration, 19 — 1.30 A. M. 
18 — 4.30 A. M. 
22 — 8.3O A M. 
22 — I I.3O A.M. 
2d — I.3O P. M. 



Autopsy. — The scalp over about one-half the parietal 
bone and the upper border of the squamous portion of the 
temporal bone was infiltrated with blood having a bruised 
appearance. On separating the scalp from the skull a 
flattened clot was found in the middle of this area between 
the scalp and bone. On removing the skull-cap no clot 
was found between the dura mater and the bone. There 
was a small subdural ecchymosis, subdural related to the 



SOCIETY REPORTS. 63 

middle of the squamous portion of the right temporal bone. 
A clot five inches long and two and one-quarter inches 
broad was found underneath the dura mater covering the 
two upper convolutions of the temporal lobe, and reaching 
over the lower border of the parietal and frontal lobes. 
Another clot, one inch by one and one-half inches, was 
found on the surface of the left cerebellar hemisphere at its 
anterior and lower border. No blood was found at the 
central portion of the base of the brain. On opening the 
horns of the lateral ventricles and the ventricles themselves, 
no haemorrhage was found. Sections through the ganglia 
and tracts showed that the large haemorrhage originated 
within the cerebrum, probably from a point along the 
external border of the lenticular nucleus. 

II. — EXTENSIVE CORTICAL SOFTENING. 

This specimen was removed from a man who in 1884 was 
in the wards of the Philadelphia Hospital, but left and found 
his way back into the out-wards, where a few days ago he 
was attacked with apoplexy, He had a small right leg — 
an old atrophic paralysis; it was two or three inches shorter 
than the left leg, and much smaller in all its measure- 
ments. 

The arms are apparently of the same size ; if there is any 
difference, the right is larger than the left, as is found in 
right handed men. 

His condition on November 21, 1888, at three P. M., was 
noted as follows : He lies upon his back with his head 
turned toward the left ; opens and closes his eyes from time 
to time, and moves them about in different directions. His 
breathing seems somewhat labored, with some tendency to 
ascent and descent, but no true hiatus. Nothing can be 
determined from the man himself, as he is not conscious to 
respond to questions or to perform any willed movements. 
He has a tremulous movement of the extremities. It is 
difficult to obtain any definite results as to sensation. Sharp 
points are evidently felt on the left side of the face. He 
does not show evidences of sensation on either side of the 
trunk or the extremities ; when tested by a pin, the results 
are unsatisfactory. His right arm is contractured at an 
angle of a little more than 450 over his abdomen. His 
fingers are turned inward, slightly clawed; the middle, ring, 
and little finger are more firmly flexed than the index finger 
or the thumb — the index finger and thumb being brought 
together in nearly a pen-holding position. He has little or 
no power in the right arm, but does occasionally use it, 



64 SOCIETY REPORTS. 

although he cannot fully extend it nor use the fingers and 
hand. 

His right foot and leg have a purplish appearance — toes 
are all clawed and bunched together ; the nails are very 
deficient. The whole foot is in a bad vaso-motor or trophic 
condition. The leg does not seem cold. He does not move 
the right leg — the palsied and atrophied one— but he fre- 
quently moves the left arm and leg, and the latter is quite 
spastic at the knee. 

Knee-jerk is abolished, both on the right and left sides. 
His condition as to motor power seems to be that he has 
an old palsied and atrophied lower right extremity, and is 
at present suffering from an apoplectic attack, which has 
affected his right face and arm, and has probably deepened 
the paralysis of his right leg, if this was not already com- 
plete. 

The electrical reactions to faradism, November 22, 1889: 
The muscles of the quadriceps extensor on the right side 
respond well, but other muscles of the thigh do not. There 
is no response in the right leg to the strongest currents. 
At the plantar surface of the foot a medium current pro- 
duces contraction of the flexor brevis digitorum, and flexor 
brevis pollicis ; the others do not respond. His urine 
passes involuntarily. 

The pupils are equal, with a median degree of dilatation. 
The wrinkles on the left forehead are much more defined 
than those upon the right side ; orbicularis palpebrarum of 
the left side is much stronger than on the right. The right 
side of the face and mouth droop somewhat. 

This man has the peculiar state of consciousness noticed 
in some cases of apoplexy, namely, while irresponsive to 
questions and tests, he opens or half opens his eyes and 
looks about, as if half conscious of his surroundings. He 
does not speak, nor does he seem to know what is said to 
him. 

The following notes were taken November 22, 1889: 
There is a decided deviation of both head and eyes to the 
left. The pupils remain about the same as before. The 
sensory and motor symptoms are unchanged, except that 
the spasticity of the muscles of the left thigh is increased, 
producing flexions of the leg at an obtuse angle to the 
thigh. There is slight spastic contraction of the flexor 
muscles of the left arm, but not nearly so well marked as 
that of the thigh on the same side. He moves his left arm 
at intervals, but no voluntary movements of his left leg are 
noticed. The whole of the right side is immobile. On the 



SOCIETY REPORTS. 65 

next day there are no changes in the symptoms except that 
all are more marked and the patient is failing rapidly. He 
died at 3.45 P. M. 

Autopsy. — November 23, 1889. The upper extremities 
of the right ascending parietal and frontal, and right supe- 
rior frontal convolutions, seem to dwindle in size as com- 
pared with the corresponding convolutions on the opposite 
side ; large diffused area of cortical softening, involving 
about one inch of the ascending parietal, lower border of 
the superior parietal, and entire inferior parietal convolu- 
tions on its lateral aspect, partly on its Sylvian aspect. 
One of the branches of the cerebral vessels was occluded, 
and the middle cerebral itself, where it gives off its four 
cortical branches, is partly occluded. Loose clots are 
found in several portions of the middle cerebral region. 
There are no lesions of the interior of the cerebrum. The 
cord was removed and will be subjected to microscopical 
examination. The kidneys show considerable interstitial 
changes. 

TUMOR OF THE BRAIN (EXHIBITED BY DR. GUY HINSDALE). 

The patient from whom this tumor was taken was under 
the care of Dr. R. M. Girvin, of West Philadelphia. He was 
seen by Drs. W. YY. Keen, Morris J. Lewis and C. A. Oliver. 
As Dr. Keen will report the case in full elsewhere, I will 
state only the main facts relating to it. 

CASE OF N. F., aet. 17. — In November, 1886, he fell 
from the roof of a stable twenty feet, breaking his right 
thigh and left forearm. He also struck and cut his chin, 
knocking out one of his front teeth. His head was not 
known to have been struck. He was rendered unconscious 
by the fall for a considerable time, but by the next day all 
the cerebral symptoms had passed away. Consumption, 
diabetes and insanity exist in three persons in the two prior 
generations of his family. His father, his sister and himself 
also have been subject to asthma, and he to chronic nasal 
catarrh. 

In April, 1889, his right knee sometimes gave way under 
him, and gradually the right arm became affected to a less 
degree, and, as throughout the whole case, so in these two 
limbs, a curious alteration took place, the leg sometimes 
being weak without the arm being attacked, and vice versa. 
Headache began about this time with a marked dragging 



56 SOCIETY REPORTS. 

gait, and sometimes nausea and vomiting. Soon afterward 
two convulsive attacks occurred with blindness. 

Dr. Keen saw him first on October I, 1889. The evi- 
dences of tumor were very clear, and with it he had 
ophthalmoplegia, both interna and externa. This ophthal- 
moplegia varied curiously in degree from day to day. The 
lower part of the right face was also paralyzed. In view of 
the extensive symptoms, both of the cortex and the base, 
it was thought that one very large tumor, or possibly two 
small ones, existed, and it was decided not to operate. The 
boy died on November 18th. The post-mortem was made 
thirty hours after death. The outer surface of the brain 
looked entirely healthy, but the moment that the median 
surface was exposed a tumor was found protruding into the 
median fissure from the left side. In the manipulation 
necessary to remove the brain from the skull, this tumor 
enucleated itself. It was 33^ inches by 2^ inches, and lay 
directly under the motor area ; it lay in the white substance 
and extended well down toward the base. 

DISCUSSION. 

Dr. Oliver. — As it is the intention of Dr. Keen and 
myself to present the details of this case in full at a future 
time, I will merely state that when I first saw the patient 
there was a marked double neuro-retinitis of equal degree 
of swelling and densitv, associated with right homonymous 
hemianopsia ; the remaining fields being limited to ligl - 
perception, which on the right side had become almost 
entirely lost. Both pupils were dilated to seven millimetres, 
and the irides were absolutely immobile to the strongest 
light stimulus. All of the extra ocular muscles were 
impaired in both monocular and associated action ; the 
utmost movement of the superior recti were about four 
millimetres ; the inferior about three millimetres ; right 
associated movement about one or two millimetres ; left 
associated movement still less ; whilst internal associated 
movement could not be obtained at all. There was also 
ptosis, more pronounced on the right side. 

Upon a second visit two days later, the partial external 
ophthalmoplegia had altered in relative amounts of muscle 
action, whilst the left pupil had become smaller, though the 
iris was still immobile to light. 

Two days after this the remaining field of the right eye 
had become "black blind." 

Dr. Hinsdale also exhibited three large sections of a 
brain tumor from a patient of Dr. H. C. Wood (case reported 
in the University Medical Magazine, Phila., April, 1889). 



VOL. XV. February. 1S90. No. 2 

THE 

Journal 

OF 

Nervous and Mental Disease. 



©vicunal Articles. 



PARALYSIS OF SERRATUS MAGNUS. 

By ROSS R. BUNTING. M. D. 

TM.. aged twenty-four, white, married, presented 
himself, September 16, 1889, at Philadelphia Poly- 
clinic Service of Dr. Chas. K. Mills, with the follow- 
ing history: June 7, 1SS9. at 4 A - M - w hiie at night-work in 
a dye-house in Wilmington, Del., he noticed he could only 
raise his right arm half way to the shoulder. He had some 
piin in the shoulder at the time, which continued at inter- 
vals for two weeks, not only when he attempted to raise his 
arm, but when it was perfectly quiet. General health good. 
Father died at forty-five of sun-stroke ; brother and sister 
living in good health. 

Present condition : Very slight wasting of muscles of 
right shoulder as compared with the left. When the arm is 
at rest there is not much deformity. .Fig. I. 

The inferior point of left shoulder is lower than the 
right ; the lower angle of right scapula somewhat nearer 
the spine than the left. With right arm elevated ^Figs. II.. 
Ill . the scapula is raised up and projects behind in a wing- 
like manner ; the inferior angle goes backward toward the 
spine, external angle upward and forward. He cannot 
thrust the scapula forward as in the left or well side. He 
can only raise his arm halfway to the shoulder. 

Farado-contractility abolished ; reactions to galvanism 



68 



ROSS R. BUNTING. 



Mm 
mm 




Fig. I. 



t J m 




Fig. II. 



Fig. III. 



PARALYSIS OF SERRATUS MAGNUS. 69 

present, but altered ; modal changes ; chest-wall smoother 
on right than on left side ; insertions of serratus (sixth to 
ninth ribs) are not seen during forced inspiration. From 
the inability of the patient to raise the arm to the horizontal 
position, there is apparent involvement of the deltoid. 
" The arm is raised least by the posterior and most by the 
anterior fibres (of deltoid), but even the latter only elevate 
it to a right angle with the trunk" (Gowers). According 
to Allen ("Human Anatomy"): "When the entire 
muscle (serratus magnus) contracts, the ribs being fixed, 
the scapula is drawn forward (adducted) and held firmly 
against the thorax, thus enabling the muscles arising from 
the scapula to secure definite lines of traction. The most 
important of these is the deltoid, which cannot effectively 
raise the arm from the vertical to the horizontal position 
unless the scapula has been previously fixed by the ser- 
ratus magnus." 

Niemeyer says (" Text-Book of Practical Medicine," vol. 
ii., p. 336) : " The serratus is especially required in the act 
of elevating the arms above a horizontal level, as it then 
draws the lower angle of the scapula outward and turns the 
glenoid cavity of the joint upward. It is by this act alone, 
and not by the contraction of the deltoid, that we are en- 
abled to lift the arm above the shoulder. When the serra- 
tus is paralyzed, the inner border of the scapula, and par- 
ticularly its lower angle, instead of lying against the chest, 
stands up like a wing, drawing up a three-cornered fold of 
skin before it and admitting of our reaching deeply into the 
subscapular fossa. The antagonistic muscles, the trape- 
zius and levator scapulae, have drawn the superior angle 
upward, and the weight of the arm and the pectoralis 
minor have depressed the external angle and thrown it 
forward." 

In most of the cases reported there is a history of trau- 
matism. Ross (" Diseases of Nervous System") reports the 
case of a man having fallen upon his right shoulder, in 
which the characteristic deformity was present. The man 
was able, but with some difficulty, to raise his arm above 
the horizontal level. Ross attributes the paralysis in this 



yO ROSS R. BUNTING. 

case not to direct injury to the muscle, but to " injury and 
consequent neuritis of the long thoracic nerve as it passes 
through the scalenus medius, caused by the sudden con- 
traction of the muscle when the patient threw out his right 
arm in order to protect himself while falling." 

G. V. Poore (" Electricity in Medicine and Surgery") 
relates a case in which the patient " over-exerted himself 
and says he strained his right arm, and complained then 
and some time afterward of severe pain in right shoulder 
and arm. One point of great interest in this case is the 
time of the appearance of the paralysis, which was not till 
three months after the date of the mishap to which the 
patient attributes his troubles. The strain seems to have 
affected the brachial plexus, and to have caused a sub- 
acute attack of neuritis, as evinced by the pain and tender- 
ness along the nerves and the congestion and sweating of 
the hand." 

According to Erb (" Ziemssen's Cycl. of Med.," vol. xi., 
p. 530) : " Paralysis of the serratus, both unilateral and 
bilateral, has not unfrequently been observed after over- 
exertion of the muscles of the shoulder, as in mowers, 
puddlers, shoe and rope-makers. These various circum- 
stances explain why paralysis of the serratus muscle is far 
more frequent in men than in women, and chiefly occurs 
on the right side. ' Catching cold' is also a frequent cause, 
numerous cases having been reported in which the affection 
has been produced by exposure to draughts, by sleeping on 
damp ground or near a damp wall." 

The paralysis in our patient, T. M., was evidently due 
to this latter cause, as it occurred while at work during a 
damp night. The treatment recommended was galvanism 
and massage and the remedies for rheumatism. The treat- 
ment of these cases is not very satisfactory, especially as 
regards quick recovery. 

Erb says : " After having made its appearance suddenly 
or gradually, it may remain stationary for a variable period, 
often for many months, and it only very gradually termi- 
nates in recovery." This statement is verified in the treat- 
ment of the case reported. His physician, Dr. Stubbs, of 
Wilmington, Del., writes (November 8, 1889) that his con- 
dition is about the same as when he first presented himself 
at the Polyclinic. 



THE KNEE-JERK AFTER SECTION OF THE 
SPINAL CORD. 1 

By EDWARD T. REICH ERT, M.D., 

Prolessor of Physiology, University of Pennsylvania. 

SINCE Westphal and Erb introduced the knee-jerk, or 
the patellar-tendon-reflex, or knee phenomenon, as 
it is sometimes called, as a diagnostic factor it has 
assumed a position of questionable value, and of late years 
generally been looked upon with increasing distrust. Why 
this should be seems evident in the extensive and acute 
observation demanded in its study ; in the uncertain char- 
acter of our knowledge regarding its true nature and its 
full significance; and in the almost entire absence of infor- 
mation cf the conditions, normal and abnormal, which 
affect it. 

While the nature of the knee-jerk is not definitely 
known, there can be no doubt that its manifestation de- 
pends upon the functional integrity of a reflex arc con- 
necting the quadriceps femoris with cerebro-spinal centres, 
and that the essential part of this is found in groups of 
cells constituting the proper centres in the spinal cord. 
Other things being equal, the extent of reaction when the 
tendon is struck depends : first, upon the condition of the 
reflex arc, which when affected, as in tabes dorsalis, where 
the sensory paths are interfered with, is diminished or lost, 
or as in lateral sclerosis, where perhaps the spinal cells are 
indirectly excited, is exaggerated ; second, upon the degree 
of tension placed upon the patellar ligament, the reaction 
increasing with the tension up to a certain point; third, 
upon the strength of blow, the reaction increasing with the 
degree of stimulus. 

Should the tendon be repeatedly struck at proper inter- 
vals by blows of like strength, the successive reactions 
will, as a rule, be practically of the same extent, but 
occasionally more or less distinctly exaggerated or dimin- 

1 Read before the American Society of Physiologists, December 28, 1889. 



72 EDWARD T. REICHERT. 

ished, and, at times, to a remarkable degree. These inci- 
dental or unexpected modifications in the average reaction 
have been the cause of some confusion, and the actual 
reasons for their occurrence were not apparent until the 
discovery of Jendressek ("Deutches Archiv. f. klin. med,' 
Bd. 33, S. 177, 1883) that if the hands were clinched imme- 
diately before the tendon was struck the knee-jerk was 
greater than when the individual was perfectly quiet- 
While this significant fact does not seem to have been fully 
appreciated by him, it has fortunately led to investigation 
in this country, which has been the starting point of obser- 
vation of rare clinical importance, and which has already 
thrown much light upon this obscure subject. 

Mitchell and Lewis (" Philadelphia Medical News," Feb., 
1886), and Mitchell {ibid., June, 1888) found that any move- 
ment, if at all decided, and that a vast range of sensations, 
if made or perceived simultaneously with the tapping of the 
tendon, would exaggerate the reflex ; and, further, if a gal- 
vanic current were passed through the anterior part of the 
brain it was also increased, probably owing to "a complex 
effect made up of sensation, motion, emotion, and some 
other more immediate affections of the brain." In Lom- 
bard's studies ("American Journal of Psychology," Oct., 
1887) we note most important additions to our knowledge 
of the variations which occur in the normal knee-jerk. He 
found that it suffers a diurnal variation, being highest in the 
morning ; is increased after each meal ; is diminished by 
muscular or mental fatigue ; is increased by mental activity ; 
is affected by the weather, being in general increased by a 
fall of temperature and decreased by a rise, rising and fall- 
ing with the barometer, but not visibly influenced by the 
direction of the wind, the humidity or electrical potential 
of the atmosphere. In general, whatever increa ed or 
diminished the activity of the central nervous system simi- 
larly influenced the knee-jerk. Moreover, voluntary move- 
ments and sensory irritations, even when not strong 
enough to cause a reflex, would when synchronous with the 
blow upon the tendon increase the reflex. Strong emotions, 
even during sleep when the dreams are vivid, acted simi- 



THE KNEE-JERK. JT> 

larly. Thus music, the cry of a child, a knock at the door 
would affect the degree of reaction. 

The fact that the volitional movements, sensations, or 
emotions must occur simultaneously or slightly antecedent 
to the tapping of the tendon to reenforce the reaction, led 
Bowditch and Warren (" Boston Medical and Surgical 
Journal," May, 1888) to make some investigations to deter- 
mine how the extent of the knee-jerk would be affected by 
varying the interval of time at which the blow on the tendon 
followed the volitional movement for reinforcement. As 
the result of 551 normal and 624 reenforced knee-jerks in 
the same individual, they found " that if the blow follows 
the signal [for a volitional movement] at an interval not 
greater than 0.4," the reenforcing act increases the extent of 
the knee-jerk. If the interval exceeds this amount, a 
diminution of the knee-jerk results. If, however, the inter- 
val is prolonged to 1.7, "the reenforcing act is without 
effect on the knee-jerk." 

Thus we find that the knee-jerk is temporarily modified 
by many normal conditions, and that it may undergo de- 
cided momentary variations through a volitional movement, 
sensation, or emotion occurring at about the time of the 
blow upon the tendon, and that the volitional movement 
may reenforce or inhibit the normal degree of reaction 
depending upon the time of its occurrence in relation to the 
time of tapping the ligamentum patella. 

In all the instances where incidental reinforcements or 
inhibitions of the knee-jerk occurred, it seems evident that 
the mind played an important part, either in the origination 
of the volitional movement or the emotion, or in the percep- 
tion of the sensation. It was therefore suggested by Dr. S. 
Weir Mitchell that experiments be made upon the lower 
animals, in which the spinal cord was previously cut, to 
learn if similar alterations could be induced where all cere- 
bral action would be cut off. I accordingly performed 
twelve experiments on dogs, which were anaesthetized and 
the cord cut in the lower cervical or upper dorsal region. 
In all cases the operation was practically bloodless, save 
one, where the haemorrhage amounted to less than three 



74 EDWARD T. REICHERT. 

ounces ; and the sections of the cord were complete, as 
shown by autopsies. Immediately after the section the 
reflexes are diminished, but in the course of a couple of 
hours or even less are normal, when the animals may be 
studied. To accomplish this, the dog is placed upon his 
side on the table and held gently but firmly by an assist- 
ant ; the leg is suspended, the tendon struck, and the 
reaction recorded, as in Lombard's experiments on man. 
An additional record was also made, by a suitable recording- 
apparatus, of the time of the. application of the reenforcing 
stimulus and that of the occurrence of the reaction. The 
stimulus was either mechanical, by strongly pinching the 
toes of the opposite foot, or electrical, where the electrodes 
were thrust into the skin of the opposite leg or into the 
upper part of the peripheral segment of the spinal cord, and 
an induction-current used of sufficient strength to cause 
pain when applied to the hands. More or less trouble was 
experienced in keeping the animals quiet, to prevent a dis- 
arrangement of such a complex piece of apparatus and avoid 
inaccurate records, but with much care it was found in all 
cases, without exception, that there was never any posi- 
tive evidence that the knee-jerk was affected in any way 
by these conjoint excitations, no matter what their true 
relations were in conjunction with the blow upon the 
tendon. 

These uniform results therefore indicate that the re- 
enforcement or inhibition of the knee-jerk are dependent 
upon some peculiar influence exerted by the cerebral 
centres. 



A CASE OF ACUTE MELANCHOLIA, DURING 
THE PROGRESS OF WHICH THERE AP- 
PEARED ARGYLE-ROBERTSON PUPIL. 
WITH ABOLISHED PATTELLAR RE- 
FLEX ON ONE SIDE AND MUCH 
DIMINISHED ON THE OTHER. 1 

By H. A. TOMLIXSON, M.D., 

Assistant Physician to the Friends Asylum for the Insane, Philadelphia. 

MR. J. P. D. was admitted to the Friends Asylum, as 
a patient, July 3, 1889, with the following history : 
Is 49 years old, married, and has two children. 
Born and lives in New Jersey, and is a bank-teller by 
occupation. 

In his younger days he worked at the trade of carriage 
painter and trimmer. He gave his trade up after a number 
of years on account of his health, and went to farming. 
After six years he gave this up also, because it was too 
hard for him, and took a position as teller in a bank. He 
has always been a very industrious and morbidly conscien- 
tious man, inclined always to look on the dark side. For 
the last ten years he has been working beyond his strength, 
and has suffered very much during the most of that time 
from indigestion He has had occasional attacks of de- 
pression, more or less severe, and during these attacks of 
depression has suffered from insomnia and anorexia. 

For a long time Mr. D. had been keeping the accounts 
of two other organizations besides his regular clerical work 
at the bank, and about three months ago began to work at 
night also. He began now to suffer from insomnia and 
constipation, from which he had always suffered ; became 
worse, so that he was obliged to take medicine to relieve 
it. He did not care for food, and what he ate only added 
to his discomfort. From being a quiet, considerate and 

1 Read before the Philadelphia Neurological Society, December 23, 1889. 



J 6 H. A. TOMLINSON. 

self-contained man, he became changed to an irritable, 
restless and peevish one. He began to manifest unusual 
and unreasonable annoyance about small business trifles, 
and became intensely depressed and despondent. 

About this time he discovered a small error in his 
accounts, and began to dwell upon it, until he came to 
believe that he had involved himself, that his sureties 
would be held responsible for his error, that it would take 
all he possessed to reimburse them, he would be left penni- 
less, and would not be able to provide for his family. 

These delusions have persisted and become more per- 
fectly defined, until now no amount of persuasion or argu- 
ment has any influence in dislodging them. 

He was under active treatment for two months previous 
to his being brought to the institution, but although his 
physical condition improved somewhat, his mental condi- 
tion grew worse, until finally his family brought him to the 
institution for treatment. 

At the time of his admission he was found to be taciturn 
and disinclined to answer questions. There was also 
marked failure of memory, with confusion on attempting to 
express himself on general subjects ; but he did not hesitate 
to talk about his delusions, dwelling most particularly on 
those relating to his property. His physical condition was 
very bad. He was pale and much emaciated, his counte- 
nance expressive of anxious distress. 

He is a small slight man, with brown hair and eyes and 
high narrow and prominent forehead. He is narrow-chested, 
stooped, and with the left shoulder higher than the right. 
Tongue pale and flabby, with slight coating in the centre. 
Pulse 120; temperature 98%° ; heart-sounds normal, but 
weak, no dilatation ; lungs normal ; respiration 24. Ex- 
amination of the urine gives a negative result, the only ab- 
normal constituent being a slight excess of urates. His 
bowels were moved the morning of his admission. 

During the first two days of his residence in the institu- 
tion his condition remained unchanged, excepting that he 
grew weaker; at the end of that time he became restless 



ACUTE MELANCHOLIA. J J 

and excited, and was most of the time in a profuse per- 
spiration. 

On the evening of the third day after his admission he 
asked his attendant for a knife to kill himself with. He 
was put to bed and placed upon liquid diet. He was better 
the next morning, and his pulse came down to 108. His 
pulse was peculiar, in that it had a hard feeling, as if there 
was a considerable degree of arterio-sclerosis ; but a care- 
ful study of the pulse showed this condition of apparent 
hardening to be due probably to vasomotor spasm. Mr. 
D 's physician had stated that this condition of the pulse 
had existed for a long time previous to his coming to the 
institution, He began at this time to grow apprehensive 
about his family, feeling that his conduct had, or would, 
destroy them. He became more excited, and developed 
auditory and visual hallucinations, seeing and hearing 
people, with whom he had been familiar, in his room. 

During the next few days his condition remained prac- 
tically the same, excepting that his pulse fell to 98. His 
bowels began to move every morning, and he slept a little 
better. About this time it was noted that Mr. D. had three 
periods of marked depression, very nearly uniform, during 
the day, and lasting about two hours — occurring after he 
waked in the morning, in the middle of the day, and in the 
evening. The depression was most profound on waking. 

At this time a hot bath, followed by friction, and given 
at bed time, was added to the treatment. He was also 
given a wineglass of malt every three hours. During the 
next week his general condition remained comparatively 
unchanged. He has developed a new delusion, to the 
effect that when he came here he assumed the responsibility 
for the expenses of the institution and its management ; 
and one to the effect that the other inmates and the attend- 
ants did not get enough to eat. His original delusions 
have been dominated by these last two new ones, 
excepting the delusion of poverty, which is merged in that 
of his responsibility. During the next week there was no 
change in Mr. D.'s mental condition nor the character of 
his delusions. In the early part of the week he had a 



J 8 H. A. TOMUXSOX. 

crapulous diarrhoea, caused by undigested food. He had 
been eating at table, and his mind was so occupied with his 
delusions that he did not pay enough attention to his meals 
to chew his food properly. He was placed upon a special 
diet and the diarrhoea ceased in a day or two. He had 
slept fairly well and his pulse has ranged from 84 to 96. 
Two different times during the week Mr. D. was rational 
for a couple of hours. His delusions did not change as to 
subject and were the rest of the time as active as ever. 
Physically, he had been gaining steadily, but very slowly. 
At this time attention was called to the fact that, even 
in twilight, his pupils were minutely contracted. Examina- 
tion showed that there was no reaction to light, but accom- 
modation was not affected. There was no tremor of the 
tongue. The patellar reflex was entirely abolished on the 
right side and much diminished on the left. There was 
also quantitative electrical change. During the next two 
weeks his condition remained about the same, except that 
his physical condition slowly improved, while at the same 
time he became restless and generally distressed. His 
delusions, though unchanged in subject or character, were 
less active. His urine was examined again and found 
normal. The condition of the pupils and reflexes remained 
the same. His pulse during this time kept at about 96 and 
was of the same character as at first. During the next few 
days the restlessness and excitement increased, so that 
unless he was compelled to sit still he was constantly on 
the move. He would not eat unless urged, because he 
thought that by so doing he was depriving the other 
patients and the attendants of food. He was very much 
disturbed also because he thought that people in the build- 
ing were being starved and injured or killed, and he tried 
to keep himself awake at night, because he felt that he 
ought not to sleep when such terrible things were going on. 
He gradually lapsed into a condition of typical melancholic 
distress, with haggard, anxious countenance, hurried res- 
piration and intense restlessness — keeping up his tramp, 
tramp, backward and forward, in his room from morning 
until night, and, if not watched, would get up in the night 



ACUTE MELAXCHOLIA. 79 

and tramp also. During this time he lost all he had gained 
in weight, and became, as a matter of course, much emaci- 
ated and exhausted. The eye ground was examined at this 
time, but with negative result, only a little narrowing of the 
arteries being found, which corresponded to the condition 
of the radial arteries. Refractive error was also noted. 
There was noted a considerable degree of ankle clonus on 
the right side at this time also. During the existence of 
this intense excitement there was no interference with 
digestion and his bowels were moved regularly. This con- 
dition lasted for about ten days, after which it began to 
subside, and with its subsidence came a marked change in 
his general condition. His pulse from being, during this 
distressed period, no to 120, small, hard and feeble, fell to 
72, and became full and soft. The reflex iridoplegia dis- 
appeared, as did also the ankle clonus, and the patellar 
reflex began to improve. His physical condition improved 
also. 

At this time his delusions began to change. From 
being troubled about the people in the house, he began to 
be troubled about his family, and talked about them a great 
deal — accusing himself of great wickedness and of failure in 
his duty toward his family, believing that his conduct had 
ruined them. Another delusion which developed at this 
time and continued to the last, was to the effect that he had 
assumed the responsibility for the management of the insti- 
tution, and that by doing so he had wilfully made his 
sureties responsible for his conduct, and that he had no 
means to compensate them. This was a modification of 
one of his original delusions to the same effect, but which 
had been for the time being lost sight of. It will be seen 
that all of his delusions hinged upon and were built up 
from his original delusion of poverty and responsibility, 
they being changed by the influence of his new surround- 
ings into the different forms in which they were manifested 
during his residence in the institution. The only thoroughly 
systematized delusion was the one concerning his 
bondsmen's responsibility for the management and expenses 
of the institution, and this persisted until within a week of 
his being discharged restored. 



80 H. A. TOMLINSON. 

After this he began gradually but steadily to improve, 
both physically and mentally, and although the excitement 
and distress continued in a modified degree, he began to be 
willing to discuss the possibility of his delusions being 
without foundation. He talked more about his family 
affairs also. He had, however, still to be urged to eat, 
especially meat, which he thought was the flesh of some 
one who had been killed in the house. The rest of his 
meal he would eat voluntarily. Oysters and fish he would 
also eat with but little urging. About this time he began 
to believe that his wife was shut up somewhere in the insti- 
tution. He continued, however, to write to her at home, 
not recognizing any incongruity in his conduct. He kept 
in this condition for about ten days without much change 
except steady physical improvement. At the end of this 
time he suddenly began to brighten mentally and for the 
first time, admitted without reserve the groundlessness of 
his delusions. He did not, however, give them up entirely, 
but was willing to talk about them as being delusions. He 
now became very anxious to go home, but was full of fear 
that his townspeople knew of his ill-doing and would look 
upon him as a criminal. He also began to be interested in 
his surroundings and spent most of his time out of doors. 
In another week he had given up his delusions entirely and 
became quite cheerful. He now began to take his meals at 
the officers' table, and was given the freedom of the 
grounds. He availed himself of this freedom, and spent his 
time in roaming about the neighborhood. During the next 
week his mental illness disappeared entirely, and being 
practically well, he was discharged. Before leaving the 
institution he was sent to an oculist, who found that he had 
a mixed astigmatism with hypermetropia, for which condi- 
tion he was furnished correcting glasses. 

There was nothing especial in the treatment of this case 
so far as drugs were concerned to refer to. During the first 
two weeks he had no drugs at all. At the end of that time 
he was put upon a pill of arseniate of strychnia, digitalin, 
zinc phosphide, quinine and bromide of iron, which he took 
continuously during his residence in the institution. He 



ACUTE MELANCHOLIA. 8 I 

also had hot baths, followed by friction. These baths were 
very efficient in securing sleep at night, and combined •with 
massage and Swedish movements, stimulated the circula- 
tion, kept the skin active, and aided materially in improving 
nutrition. He also had general faradization. This routine 
of treatment, combined with a carefully selected diet, and 
milk and malt between meals, was kept up from the second 
week, until the advent of the melancholic distress. At the 
end of the sixth week of his residence he became so much 
exhausted at this time that the baths and friction, the fara- 
dism and Swedish movements were discontinued. The 
massage was kept up at bed-time to aid in securing sleep. 
No hypnotic medicine was given him at any time. 

During the period of extreme distress, about ten days, 
he was given caffein and codeia with apparently good 
effect. It was while taking these drugs that his pulse fell 
from 1 10 to 72 and changed in character. As soon as he 
began to get quiet they were discontinued, and he had no 
medicine afterward except the pill before mentioned. 

There are several points of special interest in this case 
to which I would like to call attention. In the first place, 
the patient's condition on coming to the institution, the 
extreme exhaustion and emaciation, the intense depression, 
with a history of long-continued anorexia and impaired 
digestive power — all these conditions combined, making it 
probable that even if the patient did not speedily die of 
inanition, his residence in the institution would be a pro- 
longed one. Next, the entire absence of the ego in any of 
his delusions, while at the same time his self-accusations 
approximated very nearly to that delusion which always 
suggests a bad prognosis the commission of the "unpardon- 
able sin." Lastly, the appearance, at the end of the 
fourth week, of the "Argyle - Robertson" pupil and 
abolished patellar reflex, and their persistence for a 
period of more than six weeks. This condition of 
the pupil would, of course, suggest paresis, but the 
absence of tremor of the tongue and the abolition rather 
than the exaggeration of the patellar reflex, pointed 
toward locomotor-ataxia ; but there were no pains, stag- 



82 H. A. TOMLINSON. 

gering gait, or inability to walk with the eyes closed. 
The conclusion reached at the time was that these symp- 
toms indicated a condition of general ataxia due to exhaus- 
tion and malnutrition, and not a specific condition. Another 
singular symptom was the character of the pulse, which 
suggested immediately atheroma and kidney change, both 
of which, however, were absent. This condition of the 
pulse could be accounted for on the same hypothesis as the 
pupillary condition, both being due to sympathetic irrita- 
tion. After the period of distress had passed, and he 
became more conscious of his surroundings and the possi- 
bility of his continued illness, there was redeveloped the 
suicidal impulse which had existed in the beginning. He 
tried very hard to mask these impulses when they came, 
and there were several occasions when if an opportunity 
had offered he would have made way with himself. He 
referred to this after his recovery, and said that he had 
kept it to himself purposely, so that if he found that he was 
not going to get any better, no suspicion having been 
excited, he would have a better opportunity to carry out his 
intention of self-destruction. However, his intention was 
suspected, and he was carefully watched always. 



TREPHINING FOR EXTRA-DURAL HEMOR- 
RHAGE. 1 

By JOHN B. DEAVER, M.D., 

Demonstrator of Anatomy and Lecturer upon Surgical Anatomy in the University of Pennsyl- 
vania; Attending Surgeon to the German, Philadelphia, St. Mary's, and St. Agnes' 
Hospitals, Philadelphia, Pa. 

APPARENTLY much has been done in the past two 
years in brain surgery, but by far the greatest number 
of operations and reported successes have been for 
focal or Jacksonian epilepsy. In this class of cases the im- 
mediate results have been good, but can we say this of the 
remote ? No ; and therefore in my judgment beyond giving 
temporary relief, or beyond holding the trouble in abeyance 
for a time, these operations have accomplished most in dem- 
onstrating the amount of manipulation the brain is capable 
of permitting, providing that this is done by skilled hands 
and that every possible antiseptic precaution be taken. 
The lateral ventricles have been tapped, but this offers no 
more than temporary relief. It does not by any means 
remove the factor, which is slowly, but surely, killing the 
patient. This is true to a great extent in the cases of 
tumors, as we know the most common forms of brain 
tumors are tubercular, sarcomatous, and syphilitic, and 
therefore in the event of their successful removal the 
patient is not restored to a normal condition, but is left 
crippled. More favorable results have been obtained in 
tumors springing from the dura mater or agglutinated 
membranes, which are not strictly tumors of the brain 
substance, but invade it by pressure, excavating for them- 
selves a bed or nest. Contrast with the above, trephining 
for intra-cranial haemorrhage, particularly of the extra- 
dural variety. Here the operation, if done early, is in 
every sense a life-saving agent, practical as well as perma- 
nent in its results in the majority of cases. 

We have four varieties of intra-cranial haemorrhage : 
i. Where the blood finds its way between the 
i Read before the Philadelphia Neurological Society, January 27, 1890. 



84 JOHN B. DEA VER. 

inner wall of the cranium and the dura mater. 2. Where 
it finds its ways into the sub-dural space. 3. Where it finds 
its way into the sub-arachnoid space and into the meshes 
of the pia mater. 4. Where it escapes into the substance 
of the brain or into its ventricles. 

Erichsen gives the third variety as the most common 
form of intra-cranial haemorrhage, while Prescott Hewitt 
gives the second variety as the most common. In the 
cases which I report to-night, and in which I trephined, all 
were of the extra-dural variety. When blood is poured out 
between the dura mater and the bone in cases of fracture, 
the vessel or vessels that are, as a rule, torn, are the middle 
meningeal artery or its branches. Mr. Jacobson has shown 
that the branches of this artery are more frequently rup- 
tured than the trunk. The vessel is very frequently torn at 
the point where it crosses the anterior inferior angle of the 
parietal bone. The reasons for this are : 1. The bone at 
the site of the groove for the artery is very thin. 2. The 
vessel is so frequently buried in the bone that fracture with- 
out laceration of the vessel is hardly possible. 3. This part 
of the skull is peculiarly liable to be broken. 

It has been shown that the artery may be ruptured by 
force sufficient to occasion detachment of the dura mater, 
but not great enough to fracture the skull. Next to the 
middle meningeal the most frequent source of extra-dural 
haemorrhage is the lateral sinus. In referring to the 
attachment of the dura mater to the cranium, we find that 
it.is intimately adherent to the bone forming the interior of 
the wall of the skull, therefore this variety of haemorrhage 
in this situation is barely possible. Over the vault of the 
cranium its attachments are comparatively loose, except 
along the lines of the sutures. Sir C. Bell has pointed out 
that the dura mater of the vault may be separated from the 
bone by the vibration produced by a blow. Strike the 
skull of the subject with a heavy mallet ; on dissecting, 
you find the dura mater to be shaken from the skull at the 
point struck. Repeat the experiment on another subject, 
and inject the head minutely with size injection, and you 
will find a clot of injection lying between the skull and the 



TREPHINING FOR EXTRA-DURAL H^MORRHA GE. 8 5 

dura mater at the part struck, and having an exact resem- 
blance to the coaglum found after violent blows on the 
head. Tillaux has demonstrated, that the adhesions between 
the dura mater and the bone are particularly weak in the 
temporal fossa, the most usual site of meningeal haemor- 
rhage. 

In the diagnosis of extra-dural haemorrhage the follow- 
ing points are to be observed : 

Mental Condition. — May be normal, or there may be 
cerebral irritation. Unconsciousness complete or incom- 
plete, or coma. 

Condition of Pupils. — May both respond to light nor- 
mally. May both be dilated and show no response ; or 
one may be widely dilated and the other normal. When 
the dilated pupil corresponds to the injured side, it is causea, 
as pointed out by Hutchinson, by the pressure of a large 
clot, extending deeply down into the base of the skull, on 
the cavernous sinus, leading to fullness of the vessels, with 
protrusion of the eyeball and dilatation of the pupil. It is 
also accounted for by compression of the oculo-motor 
nerve by the clot. 

Respiration. — May have stertorous breathing, Cheyne- 
Stokes respiration, or cyanosis. 

Pulse. — Little changed, or rapid and feeble, depending 
largely on the severity of the concussion ; or slow and full, 
depending upon the severity of the compression. 

Limbs. — May present any of the following conditions : 
Hemiplegia, well or but little marked. On the same side 
as the one injured, indicating haemorrhage on the opposite 
side ; monoplegia, paralysis, twitching, convulsions, rigidity 
(spastic). 

Scalp. — Presence of contusion, or bogginess due to the 
injury ; the latter also due to leakage from within the 
cranium through a fissured fracture. 

The stages presented by a typicai case of extra-dural 
haemorrhage are three : 

I. Complete or partial unconsciousness, the result of the 
concussion or shock, caused by the fall or blow, as the 
case may be. 



86 JOHN B. DEAVER. 

II. Consciousness or lucidity. This stage may vary in 
length from a few minutes to several hours. " Is present in 
about one-half of the cases," says Jacobson. 

A very large haemorrhage may produce compression at 
once, as I have observed, verifying my observation by post- 
mortem examination. Compression may also come on 
immediately, caused by coexisting depression of bone, 
injury to the brain, and alcoholism. 

III. Compression. 

CASE I. — A. P., aged eighteen years, was admitted to 
the German Hospital, December 17, 1886, with pistol-shot 
wound of the left temporal region, the history of the case 
being as follows : While A. P. was playing with several 
companions, one of them with a single barrelled 22-calibre 
pistol, attempted to shoot over his head, when the hand in 
which the pistol was held being about twelve inches away 
from the side of the head, was drawn down by another 
companion, and the pistol accidentally discharged. 

Upon probing for the bullet, the external table of the 
skull, at the point corresponding to the wound in the scalp, 
was found denuded of its periosteal covering and slightly 
roughened. The patient at the time of admission presented 
no head symptoms, was perfectly conscious, and suffered 
no more pain than usually accompanies wounds. The 
wound was dressed antiseptically, and the patient put to 
bed. Upon making my visit throug hthe wards on the follow- 
ing morning, December 18th, I found that he was aphasic. I 
advised operative interference, to which he gave his 
consent. 

He was taken into the clinic, and in the presence of the 
class I trephined. The outer wall of the cranium, at a 
point measuring two inches posterior to the external angu- 
lar process of the frontal bone and two inches above the 
zygomatic arch, was exposed by dissecting up a horseshoe- 
shaped flap, from the scalp with its convexity directed down- 
wards and backwards. This was the point of the skull 
with which the ball came in contact, and being immediately 
over the base of the second and third frontal convolutions 
(the portion of the hemisphere in relation to the ascending 
limb of the fissure of Sylvius, and the lower extremities of 
the fissure of Rolando, Broca's conAolution, or the region of 
motor speech). The roughening which was detected at this 
point was caused by a small portion of the bullet imbedded 
in the outer table of the skull. The remaining part of the 
bullet was found one inch behind and below this point. It 



TREPHINING FOR EXTRA-D URAL HsEMORRHA GE. 8 7 

lay beneath the temporal muscle and was somewhat flat- 
tened. The trephine included the roughened portion of the 
skull. Upon the removal of the button of bone, which 
demonstrated that the internal table was fractured, but 
with no depression of the fragments, was seen a clot, evi- 
dently the result of a rupture of the posterior of the two 
branches of the anterior division of the middle meningeal 
artery ; this was removed, and as there was no further 
bleeding, the flap was adjusted, and the wound drained 
with catgut. The patient made a complete and uninter- 
rupted recovery. The aphasic symptoms disappeared 
shortly after the operation. 

Case II. — J. E., aged thirty-four years, white, was ad- 
mitted to the German Hospital, September 23, 1889, at 
5 P. M., when he stated that he had fallen down a hatchway, 
a distance of twenty feet. 

His condition on admission was as follows : Perfectly 
conscious, but a little dull mentally ; he was able to narrate 
the occurrence of the accident very intelligently. Respira- 
tion 14, temperature 97 ; slight lacerated scalp wound of 
the right side over the parietal eminence ; also contused 
and lacerated wound of the left elbow, opening up the 
capsule of the joint. He had perfect control of the bladder, 
being able to pass his urine shortly after he was admitted 
to the hospital. The wounds were dressed and the patient 
put to bed. 

6 P. M. — Dr. Michel, the resident surgeon, was sent for 
to see the patient as he was quite restless, showing some 
evidence of cerebral irritation. 

7.30 P. M. — Respiration somewhat noisy and labored, and 
this condition was shortly followed by a slight twitching of 
the right leg, arm and face, which continued with very 
little change until 8 P. M. f when it was followed by convul- 
sions, commencing in the right leg and becoming rapidly 
general. 

I was sent for, seeing the patient at 9 P. M. I immedi- 
ately explored the scalp wound, but could find no evidence 
of fracture. I removed a button of bone, two inches in 
diameter, from the left side of the skull, the centre of the 
button corresponding to that of the scalp wound, which I 
believed to be the point of the greatest intensity of shock 
from the fall, and where I therefore expected to find the 
maximum amount of separation of the dura mater, and 
consequently the largest amount of clotted blood, in the 
the event that I was correct in my diagnosis of extensive 
but circumscribed extra-dural haemorrhage. Upon the 
removal of the button of bone, clotted blood immediatelv 



88 JOHN B. BEAVER. 

commenced to escape through the trephine opening. I 
removed all of the clot, leaving a space between the skull 
and the dura mater, which held four ounces and one drachm 
of a 1-2000 bichloride solution. Rubber drainage tube, 
of medium size, was introduced into the bony opening, and 
brought out at the lower angle of the scalp wound. The 
wound was adjusted with silver wire sutures, and the head 
dressed. The patient lived but a short time after the 
operation, not having reacted. 

Autopsy made the following day, December 26, 1 1 A. M. 
The brain and cranial cavity alone examined. Upon the 
removal of the calvarium the surface of the dura mater was 
free of blood and otherwise normal, except at the point of 
separation already referred to. Brain removed. Dura 
mater lining sides and base of skull removed, when was 
seen a fissured fracture starting in left parietal bone imme- 
diately below opening made at operation, and extending 
into the floor.of the middle cerebral fossa, involving only 
the outer half of same. Examination of brain showed it to 
be perfectly normal except at three points on the basilar 
aspect of the temporo-sphenoidal lobe; these were evi- 
dently seats of contusion, involving only the gray matter, 
as shown by making sections of the brain. No further evi- 
dence of cranial haemorrhage or other lesions. 

Case III. — Harvey Kitchen, twenty-three years old, 
white, was admitted to the German Hospital, December 19, 
1889, 12.30 P. M., having met with an accident. He had 
fallen a distance of fifteen feet through an elevator, landing 
on the top of his head. 

His condition upon admission, as described by the resi- 
dent surgeon, Dr. Gerlach, was as follows: Complete 
unconsciousness, pupils responding to light, conjunctival 
reflexes active, respiration 24, pulse 100, temperature 99 . 
The scalp was much swollen and boggy over the whole of 
the left side and vertex, with lacerated wound of the right 
ear at the junction of the concha with scalp. The urine 
was drawn ; quantity small, normal in reaction and color; 
chemical tests for albumen and sugar negative. The patient 
remained in the above condition twenty minutes, when he 
regained partial consciousness for about five minutes ; he 
was then seized with a general epileptiform convulsion, 
lasting one minute. The convulsion, as described by the 
Sister, was thought to have commenced in the right leg. 
but it became general so soon that she could not be certain. 
After the convulsion the patient could not be aroused fully, 
but showed some evidence of consciousness when spoken 
to. His breathing was embarrassed, the pulse full and 



TREPHIMXG FOR EXTRA-DCRAL HEMORRHAGE. 89 

strong. After an interval of ten minutes he was seized 
with another convulsion, lasting about double the length of 
the first, and described by a second Sister present as corre- 
sponding with that of the first seizure ; but she too was in 
doubt about the spasm commencing in the right leg, as it 
became general so soon. Dr. Gerlach was sent for, but 
arrived too late to witness the convulsive seizures. The 
patient was now intensely cyanosed, respirations slow, 
deep, and stertorous, pulse slow and full. Upon my arrival 
at the hospital, but a moment or two later, very fortunately, 
I found his condition as above noted. Examination of the 
right side demonstrated the limbs to be slightly spastic, the 
left paretic. 

As there was but little doubt in my mind that the con- 
dition was one of intra-cranial haemorrhage, and most 
probably of the extra-dural variety, there having been an 
interval of consciousness between the reaction from the 
concussion or shock and the development of convulsions, 
I immediately prepared to trephine over the anterior branch 
of the middle meningeal artery. The scalp was quickly 
prepared for a strictly antiseptic operation, and ether 
administered. A large horse-shoe flap, including all the 
layers of the scalp, with its convexity directed downward 
and backward, was turned up on the left side by carrying 
an incision from directly behind the external angular pro- 
cess of the frontal bone to above and behind the parietal 
eminence ; then was seen a fissured fracture following the 
coronal suture. To trace it throughout its entire length, 
two further incisions were made, one following the line of 
the coronal suture, the other from the termination of the 
latter, a short distance over the right parietal bone, when 
these flaps were reflected forward and backward, almost the 
entire vertex was laid bare. 

In the subaponeurotic space and infiltrating the areolar 
tissue of the scalp was an extensive extravasation of blood. 
The fracture extended from the beginning of the coronal 
suture to about one and a half inches beyond the sagittal 
suture ; from this point a fissure extended obliquely down- 
ward and backward into the right parietal bone, also one 
obliquely forward, and to the left, involving both the right 
and left frontal bones, stopping short of the supra-orbital 
margin. There was some bleeding from beneath the bone, 
through the line of separation of the coronal suture, most 
marked on the left side. With a medium-sized trephine, an 
inch and a half in diameter, a button of bone was removed 
at a point one inch and a half behind the external angular 
process of the frontal bone ; and one and three-quarter 



9<3 JOHN B. DEA VER. 

inches above the zygoma, when the anterior branch of the 
middle meningeal artery was exposed and its ends ligated 
with catgut. The bleeding not being entirely arrested, with 
a pair of Hopkins' modification of the rongeur forceps the 
opening was enlarged in the direction of the groove in the 
squamous portion of the temporal bone, through which 
passes the posterior branch of the above vessel, when it 
was plainly to be seen that the source of the remaining 
haemorrhage was most probably this branch near its point 
of origin ; the opening was therefore enlarged in the direc- 
tion of the spinous foramen of the sphenoid bone, and after 
cutting away bone, to the extent of about one-half inch, the 
vessel was seen to be torn and bleeding freely. Both ends 
were tied with catgut, after which the haemorrhage ceased. 
The cavity occasioned by the separation of the dura mater 
was washed out with a 1-2000 bichloride solution. 

I removed a second button of bone, three-quarters of an 
inch in diameter, from a point about three-quarters of an 
inch to the left of the sagittal suture, and about one inch 
posterior to the separated coronal suture, this correspond- 
ing to the upper and posterior margin of the cavity caused 
by the separation of the dura mater. My object in doing 
this was to enable me to pass catgut-drainage through this 
opening and out of the one first made, this securing a per- 
fect outlet to any liquid that would otherwise have a tend- 
ency to collect in the cavity. Through this last opening 
I incised the dura mater and exposed the sub-dural space, 
to determine whether or not there was either the second or 
third variety of intra-cranial haemorrhage associated with 
the extra-dural which I had already checked. This proved 
negative. The incision of the dura mater was closed with 
catgut suture. The end of a rubber drainage-tube, one- 
quarter of an inch in diameter, was placed in the lower and 
anterior of the two openings made in the wall of the skull, 
and brought out at the lower angle of the scalp-wound, 
where it was fixed by a silver wire suture, loosely twisted. 
A second rubber drainage-tube, the same size as the above, 
was placed beneath the scalp-flaps, above the two trephine- 
openings, and brought out in front and behind, where it was 
fixed by a silver wire suture. The flaps were now com- 
pletely adjusted and held in apposition by interrupted silver 
wire sutures. Through the tubes a 1-2000 solution of 
bichloride of mercury was passed, and the wound dressed 
antiseptically. A hypodermic injection of one-eighth of a 
grain of morphia was given to the patient, when he was 
removed from the operating-table. Dry heat was applied 
to the body and an ice-bag to the head. He reacted well, 



TREPHINING FOR EXTRA-DURAL HEMORRHAGE. 



91 



and slept for four hours after the operation, when he awoke 
and was fairly rational. Being now able to swallow, he 
was given milk diet and ordered one-quarter of a grain of 
calomel, with two grains of Dover's powder every two 
hours. At 8 P. M., six and one-half hours after the opera- 
tion, he was perfectly quiet and entirely rational. Pulse 96, 
respiration 28, and temperature ioo° ; pupillary reaction 
normal. He was able to execute the ordinary movements 
with his extremities ; said he felt pretty comfortable, 
although he had some pain in his head ; during the night 
was somewhat restless. 

December 20th. — Condition unchanged from that of pre- 
vious evening. 

At 3.30 A. M., December 21st, he had a slight convulsion, 
beginning in right upper extremity, with flexion of hand 
upon wrist ; then forearm on arm ; when it immediately 
became general ; this lasted about one-half minute. At 
5.30 A. M. had second convulsion similar to the above and 
lasting about the same length of time. Between and after 
these convulsions he slept. 

8 A. M. — Condition of patient good, with the exception 
of pulse, which was full and bounding. In addition to the 
calomel and Dover's powder, tincture of verat. virid., two 
drops, and bromide of sodium, twenty grains, was ordered 
every two hours. 

December 23d. — Dressings changed ; no pus ; drainage- 
tubes clear; tincture of verat. virid. and bromide of sodium 
stopped. 

December 26th. — Calomel and Dover's powder stopped 
since slight mercurial stomatitis had developed, for which a 
gargle of chlorate of potassium and listerine were given. 
From this on the recovery was uninterrupted. 

[This patient was exhibited in perfect health to the 
Society.] 

In answer to the question, what led me to trephine in 
these cases, I will simply make a summary of the main 
symptoms of each : 

Case I. — (1) The injury to the outer table of the skull, 
as demonstrated by the probe, near the point corresponding 
to the location of the anterior branch of the middle menin- 
geal artery ; (2) aphasia coming on a few hours after the 
accident. 

Case II. — (1) Circumscribed contusion of the scalp; 
(2) period of consciousness following the accident; (3) evi- 



92 JOHN B. DEAVER. 

dence of cerebral irritation with twitchings of the side of 
the face and of the extremities opposite to the side injured ; 
(4) convulsions commencing on the side opposite to that 
injured ; (5) coma ; (6) paralysis. 

CASE III. — (1) Unconsciousness; (2) pupils responding 
to light ; (3) conjunctival reflexes active ; (4) period of 
partial consciousness ; (5) convulsions. 

In closing this paper, I would not have you understand, 
from what was said in the beginning, that I am opposed to 
trephining for focal epilepsy, brain tumors, etc. I am not ; 
but I do not consider the results in these cases as brilliant 
as in cases of extra-dural haemorrhage. 

As the subject of head injuries, both in their immediate 
and remote effects, is of interest to the neurologist as well 
as to the surgeon, it may not be out of place to tabulate my 
rules for trephining in this class of cases. 

In this paper I have given the conditions for which I 
trephine when I suspect extra-dural haemorrhage. 

I trephine also in simple depressed fracture of skull, with 
or without symptoms of compression. 

In compound depressed fractures, with or without symp- 
toms of compression. 

In punctured or incised fractures. 

In fractures of the orbital plate of the frontal bone. 

In punctures of the cribriform plate of the ethmoid bone, 
applying trephine to roof of orbit at the inner angle, thus 
opening up the most dependent part of the anterior cerebral 
fossa, and thereby favoring drainage, which is a chief indi- 
cation in this class of injuries. 

For foreign bodies in the brain. 

For impacted fractures. 

In gunshot injuries of skull. 

In contusion of the scalp, simulating depressed fracture ; 
here exposing the cranium at the seat of contusion, when, 
if depressed fracture is found, I trephine ; and also, if a 
fissured fracture, if there is any haemorrhage through the 
line or lines of fracture. 



TWO CASES OF PARALYSIS OCCURRING DUR- 
ING THE PUERPERAL STATE. 1 

By M. 1MOGENE BASSETTE, M.D., 

Instructor in Electro-Therapeutics and Clinical Assistant in the Philadelphia Polyclinic 
Clinician to the 'Woman's Hospital, Philadelphia. 

AS cases of paralysis seemingly related to the puerperal 
state are comparatively rare, and yet of interest 
from the point of view of causation and prognosis, 
it might be worth while to record with a few remarks two 
cases which I have had the opportunity of observing in the 
Polyclinic service for nervous diseases. 

Case I. — Mrs. McC, aged twenty- two, about four 
months before coming to the clinic had given birth to her 
first child. The labor was easy and short. The uterus 
was entirely freed from clots, and convalescence was nor- 
mal. Milk appeared in thirty-six hours and the lochia 
were sufficient, gradually ceasing after the thirteenth day. 
She had no fever. Three weeks after labor the patient 
seemed to be doing well ; she ate her breakfast as usual. 
An hour later, however, she was completely paralyzed 
both as to motion and sensation on the right side and also 
was aphasic, but she was not unconscious at any time. 
Sensation was diminished on the left side, particularly in 
the thorax and arm, but returned to normal on this side in 
fourteen days ; it gradually improved to some extent on 
the right side, commencing in the lower extremities. Her 
speech had also slightly improved. She had no eye symp- 
toms. Slight swelling of the hands and feet lasted about 
two weeks. 

When she first came for treatment she had paresis of 
the right upper extremity, most decided in the forearm and 
hand, the grasping power of the hand being particularly 
affected ; she had also marked anaesthesia over a portion of 
the right half of her body, the loss of sensation being to 
pain, touch and temperature. The anaesthesia was present 
in the right arm, the right half of the trunk, back and front, 
to a line about two inches above the anterior superior spinous 
process of the ilium. Another anaesthetic area, oblong in 

1 Read before the Philadelphia Neurologi:al Society, Dec. 23, 1889. 



94 M. IMOGEN E BASSETTE. 

shape, was situated in the central portion of the lower half 
of the front of the thigh. Another area was on the poste- 
rior aspect of the leg from the knee to just above the 
ankle. Other portions of the body and limbs were sensitive 
to impressions. From the history obtained from the 
patient's husband, and imperfectly from herself, she had 
apparently been completely hemianaesthetic at first, and 
sensation had gradually returned, except in the parts just 
described. 

She presented a decided form of motor aphasia. She 
could understand all that was said to her, which she indi- 
cated by the expression of her face and gestures. When 
given something to read, she appeared to understand it, 
but she used only two or three expressions for everything 
she wished to say. She could name some things sponta- 
neously, but not nouns and verbs ; and she could utter 
many words which were repeated to her. She evidently 
received auditory and visual impressions, and turned them 
in her mind into names and ideas, but she could only speak 
a few simple words. 

She remained under observation and treatment for ten 
months, during which time she made very great improve- 
ment in her paralysis, anaesthesia and aphasia. For the 
anaesthesia faradism with the dry brush was used; and a 
a faradic current with moistened electrodes was used for 
the motor paralysis. For the aphasia a system of persistent 
training was undertaken, and met with considerable suc- 
cess. Internally, she was given potassium iodide and 
tonics. When she discontinued treatment, the anaesthesia 
and paralysis had almost completely disappeared, and the 
aphasic condition was greatly improved. 

Case II. — Mrs. M. E. P., aged thirty-eight, white, mar- 
ried, was perfectly well until her last labor, which occurred 
July 3, 1888. Her labor was normal, and she was well for 
eight days. On the eighth day the nurse was absent, and 
the patient sat up most of the day. When the nurse 
returned she found the patient standing up, reeling and 
trying to get into bed, which she managed to do, and then 
became insensible. On coming out of this condition several 
hours later, she was unable to speak or to put out her 
tongue, but was not otherwise paralyzed. She remained in 
bed, and a week later was taken with a severe chill, but did 
not lose consciousness. It was found then that she was 
paralyzed in the right arm and leg. In three or four weeks 
she began to use the paralyzed side a little, and gradually 
became well enough to walk about with some assistance. 



PARALYSIS. gr 

When she came under observation, her face was drawn 
to the right side ; she could wrinkle her forehead and close 
the right eye ; and the tongue and uvula turned a little to 
the right. The right arm was a little smaller than the left 
from the shoulder to the hand. She could not raise her 
arm, which was completely paralyzed and the fingers con- 
tractured and flexed at the second phalangeal articulation. 
The thumb was flexed and drawn in over the palm of the 
hand. The right leg was completely paralyzed. Knee- 
jerk was exaggerated, and ankle clonus present in the right 
side. On the left side the knee-jerk was slight and there 
was no ankle clonus. Tactile sense was blunted on the 
right side. No cardiac murmur was present. 

This patient remained under observation only a few days. 
The first case was treated for many months. I have thought it 
worth while, however, to notice the second case, as it cor- 
responds in many points with the first, and both probably 
belong to the same category. In both the attacks came on 
comparatively soon after labor, and were probably con- 
nected with the puerperal state. Heart disease was absent 
in both cases ; in both the involvement of speech, face, arm 
and leg, and the presence of contractility to electricity 
indicated a cerebral origin for the paralysis. 

The literature of the subject of paralysis following labor 
does not appear to be extensive. The most recent paper is 
that of Dr. Lloyd in Hirst's American System of Obstetrics. 
This writer refers to the papers of Hervieux, Churchill, 
Imbert-Gourbeyre, Poupon and others. I have also found 
a few references to special cases. Lloyd objects to the term 
puerperal paralysis, if anything distinct or special is meant 
by that expression. The term, however, is a proper one 
for cases occurring at or near the time of labor, if it can 
be shown that the palsy has any connection with the 
process of labor or the phenomena of the puerperal state. 
The term is of course used only as we speak of other forms 
of paralysis with reference to their etiology. It is interest- 
ing to discuss the probable manner in which the monople- 
gia and hemiplegia which follow labor originate. Form- 
erly uraemia was regarded as the most frequent cause. 

Dr. Dercum and others have reported cases of hemi- 
plegia occurring in Bright's disease apparently without any 
vascular or other lesion of the brain ; in other words, due 
to some unilateral action of the poison on the nervous 
system. The truth probably is that some of the cases of 
so-called puerperal monoplegia and hemiplegia are uraemic 
in origin, but only in cases with chronic nephritis, and 
equally chronic disease of the blood-vessels. In both of 



9 6 



.]/. IMOGEHE BASSETTE. 



the cases reported no evidences of disease of the kidneys 
was present when the patients came under observation, but 
this was a considerable time after the occurrence of the 
paralysis. Nothing in the history of these cases indicated 
the probability of uraemia. In both the labor was normal, 
and in both the patients were doing well up to the time the 
paralysis occurred. The first patient was an unusually 
healthy looking woman ; the second was pale, anaemic, and 
not strong looking. Uraemia can probably be excluded as 
the cause in both the cases. 

In healthy women paralysis may occasionally occur 
owing to the great strain which is is put on the blood- 
vessels during labor. Still, this is very rare, the system 
seeming to adapt itself to what it has to bear. In women 
with diseased blood-vessels associated with nephritis, such 
a result may of course readily occur. There would seem to 
be no particular reason why haemorrhage should occur 
during the puerperal state unless as the result of increased 
blood pressure. 

Hysterical hemiplegia may occur after labor as under 
almost any other circumstances. These two cases, and 
especially the first, seem to present some features of hyster- 
ical paralysis. The patient was hemianaesthetic as well as 
paralyzed. Against the view that the case was of hysterical 
nature are the facts that she had an aphasia of the kind 
usually associated With destructive brain disease ; the per- 
sistency and peculiarity of the distribution of the anaes- 
thesia ; the absence of affections of the special senses, and 
also the absence of the moral and psychical symptoms 
which are usually present in hysteria. The fact that the 
patient improved but did not recover is in favor of the 
organic affection. Hysterical hemiplegia and hemianaes- 
thesia are more likely to occur on the left side of the body, 
but of course a point of this kind is not of great value. 
Hysterical aphasia occasionally occurs, but it is rare and 
usually recovered from soon. The fact of the occurrence 
of organic aphasia only indicates that embolic paralysis 
which is probably that which most usually occurs after 
labor is most likely to be the result of blockage of arteries 
on the left side of the brain. 



MORPHINE INJECTIONS FOLLOWED BY EMPHY- 
SEMATOUS GANGRENE (MALIGNANT 
CEDEMA). 

By L. BREMER, M. D., 

St. Louis, Mo. 

PRELIMINARY REMARKS. 

ONE of the varieties of septicaemia well known to, and 
dreaded by, the surgeons of former generations, but 
now almost banished from the surgical wards, is 
emphysematous gangrene, or, in modern parlance, malig- 
nant cedema (Koch). 

The general adaptation of the great principle of cleanli- 
ness, in even insignificant lesions and operative interference, 
has almost done away with this formidable foe to the 
wounded, and where it does appear it follows not, as a 
rule, in the wake of the surgeon's instruments. In our days, 
if at all, it is met with in open fractures and deep lacerated 
wounds which in some manner have come in contact with 
filthy material harboring a certain pathogenous germ. 

It is at present a well-settled fact that this form of 
wound-infection owes its origin to a well-characterized bac- 
terium, the bacillus of malignant oedema. 

This is not the place to exhaustively discuss the form, 
life-properties, habitat, and manner of growth of the bac- 
terium in question. Suffice it to say that it was first experi- 
mented with by Pasteur, who obtained it by injecting putrid 
blood into animals. They died, and Pasteur called the 
bacillus invariably found in the tissues affected vibrion sep- 
tique. Koch afterward re-discovered it by introducing 
garden-earth into pockets made under the skin of mice, 
rabbits, etc. He called the micro-organism found after the 
death of the animals, the bacillus of malignant oedema. It 
is most abundantly met with in the neighboring tissue of 
the skin-pocket and on the serous membranes of the abdom- 
inal and thoracic cavities. 

The pathological changes produced by the microbe by 
means of hypodermic injections of fluid containing the germ, 



9 8 L. BREMER. 

in animals, are diffuse oedema of the neighborhood of the 
inoculation, accompanied by emphysema. The latter is due 
to gas-formation in the tissues. The disease (in animals) 
clinically resembles anthrax, from which, however, it can 
be easily differentiated by the manner of death, by the form 
of the bacillus found, by its manner of spreading through 
the organism (the anthrax bacillus proliferating in the 
blood, the other in the tissues), and, last, by its behavior in 
the cultivating media. 

Leaving all the other distinguishing characteristics aside, 
I will only state that our bacillus, when examined under 
the microscope, is a slender rod, growing at times into false 
threads, resembling very much the anthrax bacillus, from 
which it differs by the rounded ends, the latter having both 
of its extremities slightly excavated. 

It is met with almost everywhere, to wit: in the super- 
ficial strata of manured ground, in putrefying cadavers, in 
old rags, in dish-water, etc. It forms spores, and it is gen- 
erally in this state that the bacillus occurs in the substances 
named and is introduced into the living body. 

The artificial production of malignant oedema in man has 
been observed before. Thus Brieger and Ehrlich 1 have 
described it in two cases of typhoid fever following the sub- 
cutaneous injection of tincture of musk, which probably 
contained the organisms. The patients died. I myself 2 
reported a fatal case of malignant oedema in a woman who 
had been in the habit of producing abortions on herself and 
had probably employed an unclean instrument in the last 
operation for that purpose. 

Two recently observed cases following the use of the 
hypodermic needle in morphinists are perhaps of interest to 
those who have frequent dealings with such patients. 

That the morphine-injector is very careless as to the 
condition of his syringe, and that he will continue its use, 
although every injection is sure to be followed by an abscess, 
is a fact too well known to be dwelled upon. That in such 

1 Berlin, klin. Wochschr., 1882, No. 44. 

2 Bremer on Malignant CEdema and Fat Embolism. American Journal of 
Med. 8c., June, 1888. 



MORPHINE INJECTIONS. 99 

cases the syringe is " infected" with pus-producing organ- 
isms, is well known. To what extent the weakened general 
condition, the lowered tone of the system, and the inade- 
quate or vitiated metabolism 3 of the body, favor the propa- 
gation of these pus-producers when once introduced into the 
tissues is as yet undecided. We know that even without 
special preparation of the " soil," the pyogenic staphylo- 
cocci, when introduced into animal tissues, will set up typi- 
cal suppuration. They differ in this respect from the 
bacillus of malignant oedema, of which the human body, as 
a rule, is not susceptible. But that under certain conditions 
this bacillus may invade the human organism, the following 
two cases well illustrate : 

CASES. 

Case I. — Mrs. M., aged thirty, has been the victim of the 
morphine habit for a number of years ; she has also been 
addicted to the use of stimulants to a considerable extent. 
She is stout in appearance, but her flesh is soft and flabby. 
The abdominal walls are especially thick with a large 
amount of adipose tissue. She has been in the habit of 
using the hypodermic syringe (fifteen grains of morphine a 
day), and her arms and abdomen are tattooed with the 
marks of the needle. One of these punctures had inflamed, 
and when seen by Dr. Prewitt, of this city, she had high 
fever, frequent pulse, some irregularities of the heart's 
action, anorexia, and diarrhoea. Over the abdomen, a little 
above the level of the umbilicus and between that and the 
left lumbar region, there was a broad inflamed indurated 
patch, four or five inches in breadth and five or six in length, 
which fluctuated in the centre and was resonant on percus- 
sion over this part. A thought of an inflamed hernia, with 
a flatulent knuckle of bowel included, suggested itself; but 
the history of the case excluded this. Ether was adminis- 
tered at the solicitation of the patient. Upon making an 
incision, the bistoury entered as though penetrating a bag 
of air, giving exit to a puff of exceedingly fetid gas, fol- 
lowed by a quantity of equally fetid pus. 

For a moment the possibility of having cut into a 
knuckle of bowel caused some trepidation, but a slight in- 
vestigation showed thut the gas came only from the 
abscess-cavity. 

Unfortunately none of the pus was preserved for exami- 
nation. Judging the case in the light of recent experiences 

3 Compare the furunculosts in diabetes. 



IOO L. BREMER. 

our present knowledge of gas-containing abscesses, there is 
no doubt that the bacillus of malignant oedema would have 
been found. (Compare the next case.) 

The probable carrier of the infectious material was the 
syringe, or perhaps the water in which she dissolved the 
morphine. As she injected it secretly, she probably was 
not very particular in choosing the purest article, and had, 
at times, to take any kind of water at hand. 

The incision was made free, and under thorough anti- 
septic treatment the abscess assumed a healthy character 
and rapidly filled up. A second abscess formed in the 
lower border of the indurated area of much smaller dimen- 
sions, and was opened, but presented none of the peculiar 
features ol the first. 

The further progress of the case and its treatment are 
not germane to the subject of this paper, and will not be 
dealt with here. I saw the case only after healthy granula- 
tions of the wound had set in, when none of the infectious 
material could be obtained for examination. 

Case II — M. C, aged twenty-eight, has been injecting 
morphine for the last eight years. The habit has lately 
grown upon him to such an extent that he has used up to 
thirty grains a day. In order to prevent fainting-spells, as 
he alleges, and to be competent to discharge his duties as a 
bank-officer, he was obliged to inject with the utmost quick- 
ness, and since the skin of his arms was nearly unfit for 
further injections, owing to the extensive scars, the results 
of former suppurations, he had formed the habit of injecting 
through his pantaloons into the muscles of the thigh and 
the nates. He claims that he could do this in the bank, 
unnoticed by the other employes. At the instance of his 
family he had resolved to enter upon a " weaning cure," and 
the day for its commencement had been set. Probably to 
once more enjoy the effects of the drug to the fullest extent 
before parting with it " forever," he injected for a few days 
more recklessly than ever, and presented himself on the 
morning of the day appointed for the beginning of the ordeal 
in a most wretched condition. On examination an exten- 
sive reddish-blue swelling, fully the size of two fists, involv- 
ing almost the whole of the right buttock, which had been 
of late the favorite place of the injections, presented itself. 
There were also painless nodules, representing abscesses, 
all over the body, varying between the size of a bean and 
that of a walnut. There was only a slight elevation of tem- 
perature, pulse 90, sickness of the stomach, and general 
malaise. 



MORPHIXE INJECTIONS. IOI 

A free incision having been made, an enormous amount 
of stinking, bubbling, pale reddish looking fluid, mixed with 
white streaks, burst forth. Large shreds of mortified 
connective-tissue and liquid fat were also discharged. The 
peroxide of hydrogen was poured into the cavity twice a 
day, and the enormous defect, large enough to hold a man's 
fist, healed up in a remarkably short time. 

The oxygen was resorted to from theoretical considera- 
tions. The bacillus of malignant oedema is an anaerobe ; 
exposure to the atmospheric air, or, still better, oxygen in 
some form or other will interfere with its proliferation. 
Probably, however, the simple free opening of the abscess 
would have sufficed. 

The culture-experiment (gelatine and agar) revealed the 
presence of the staphylococcus aureus and albus ; the piston 
of the syringe was planted in nutrient gelatine, and on the 
third day the unmistakable gas-formation took place around 
the leather disks. No further inoculation-experiments were 
undertaken. 

There was then a "mixed infection" in the sense of 
Briegef and Ehrlich. 4 The bacillus of malignant cedema is 
one of those microbes which, in man, are comparatively 
harmless. It takes another microbian invasion to aid the 
virus under consideration to gain a foothold in the tissues 
of the body. Experiments carried on lately in this direction 
have proved that quite a number of micro-organisms, which 
are absolutely innocuous when introduced singly, become 
pathogenic when they enter into a higher organized body 
in combination with another equally harmless microbe. 

In the two cases reported, and in others similar in kind, 
it seems that the pus-producers pave the way for the suc- 
cessful colonization of the bacillus of malignant cedema. 

Another factor which probably contributes to the greater 
facility of the microbe establishing itself in the body is to 
be found in the manner of inoculation. Experiments with a 
number of germs have proved the fact that inoculations are 
negative when made by the knife, e. g., making an ordinary 
pouch under the skin ; whereas the inoculation proves suc- 
cessful when done by the hypodermic syringe (Sputmann- 
septicaemia in rabbits). It is perhaps unnecessary to call to 
mind the many mishaps which were caused by the syringe 
during the late Elixir of Life craze. 

4 The abnormal metabolism as a predisposing agent has been alluded to 
above. Cf. loc. cit. 



periscope. 



By LOUISE FISKE-BRYSON, M.D., CHA.S. HENRY BROWN, M.D. 

INSANITY AFTER ACUTE SURGICAL OR MEDICAL 
AFFECTIONS. 

In the " University Medical Magazine," Dec, 1889, Dr. 
H. C. Wood has an interesting paper treating of this condi- 
tion, concerning which it is very important that correct 
ideas be disseminated among the rank and file of the 
profession, as cases of this kind usually come under the 
observation of the family doctor, who sometimes fails to 
comprehend the situation. Though insanity following 
acute disease varies greatly in symptomatology, there is 
generally one common fundamental brain condition ; and 
this fundamental brain condition bears no specific relation 
to the disease which has produced it, but may be the out- 
come of an altered nutrition produced by exanthematous 
disease, diathetic disorder, traumatism, or by a surgical 
operation. There are serological and symptomatical reasons 
for believing that insanities from these causes are identical 
in their nature. 

Etiological. — After disease, the symptoms develop dur- 
ing convalescence, when the specific poison has exhausted 
itself. Fevers, traumatism, surgical operation, that are 
followed by insanity, have one influence in common, i. e., 
they all tend to exhaust or impair the nutrition of the nerve- 
centres. It is known that impairment of the nutrition of 
these centres, by lack of food, combined with anxiety, is 
capable of causing symptoms similar to those which are 
present in insanities developed after disease. 

Symptomatical. — Though the cases vary much in detail, 
the general scope of symptoms and the general course of 
the disorder are identical. I. There is always mental 
confusion, a mixture of excitement and mental power. 
2. The cases nearly always end in complete recovery, if 
free from organic disease. 

Confusional insanity, a term without pathological import, 
but expressing a necessary outcome of the pathological 
state, is probably as good a name as can be found for this 
condition. In chronic diseases, accompanied by great 
bodily and mental exhaustion — consumption, gout, rheuma- 
tism, after shipwreck followed by exposure and starvation — 



PERISCOPE. IO3 

the brain-tissue gradually passes into a condition of per- 
verted and exhausted nutrition similar to that of confusional 
insanity. This form of alienation follows typhoid fever not 
infrequently, and probably constitutes the bulk of cases 
named puerperal insanity. To it, also, belongs the so-called 
surgical insanity. Within the last year the author has seen 
it develop after ovariotomy, perineorraphy, and after the 
removal of the breast for cancer. It may be due to emo- 
tional strain accompanied by exhausting circumstances. 
The mental enfeeblement following exhausting disease is 
very slowly recovered from — two years elapsing before a 
student, who had had typhoid fever, regained power of 
acquiring knowledge and doing high intellectual work. 
When confusional insanity is fully developed, there is 
almost invariably a general lack of nerve-tone — as shown 
by feeble circulation and coldness of the extremities — by 
general muscular relaxation, and failure of digestive power. 
The tongue is often so heavily coated and the breath so 
foul that the inexperienced may think digestive disorder 
the basis of the attack. The temperature varies in differ- 
ent cases, normal, low paroxysms of subnormal tempera- 
ture. On the other hand, there may be distinct febrile 
reaction, especially in puerperal cases. When fever exists at 
all, the temperature-range is remarkable for its irregularity 
and extent, extreme pyrexia being often followed by sud- 
den and marked fall below the normal. Mental symptoms 
seem to be contradictory. Many are those commonly sup- 
posed to be the outcome of paralysis of cerebral function, 
while others are sometimes considered evidence of excited, 
though perverted, cerebral activity. Mental confusion is 
the most characteristic manifestation of the disease. This 
expresses itself by inability to carry on a clear, connected 
conversation and to recognize familiar persons and places. 
The weakened judgment cannot distinguish between the 
contending claims of subjective and objective sensations. 
Realities and imagination are intermingled in hopeless con- 
fusion. Memory is pronouncedly affected, and numerous 
vivid hallucinations affect all the senses. A peculiar hallu- 
cination, so often present that it may be considered charac- 
teristic, is that another person or persons are in bed with the 
patient. (In the case cited of Mr. J., who recovered, this: 
" In his delirium, always desiring to be taken home ; con- 
stant vagary, that there are babies in the bed who are liable 
to be hurt.") The delirium is commonly mild and non- 
aggressive. It may take on an active form, or the patient 
may be habitually quiet, but subject to paroxysms resem- 
bling those of acute mania. Any form of mania may be 



104 PERISCOPE. 

counterfeited. Commonly there is fear underlying the 
aggressiveness and violence, resembling the fear of delirium 
tremens. When tremulousness exists, the likeness is very 
pronounced. The author thinks delirium tremens may be 
considered a form or variety of confusional insanity. The 
kaleidoscopic character of the hallucinations, the stupor, 
the peculiar mental state, the lack of dominant emotional 
excitement, of good bodily nutrition and of general nerve- 
force, together with the previous history of exhausting 
disease, traumatism, or emotion, should make the diagnosis 
easy. 

Treatment. — First, maintenance of bodily warmth, by 
over-heated rooms, hot-water beds or bags, by the warmest 
covering whenever the bodily temperature is sub-normal. 
Rest, massage, and exercise are hygienic measures that 
must be applied in every case. To increase the nutrition 
of the nerve-centres and general tissues of the body, iron 
combined with bitter tonics, in small or large quantities, 
strychnine given in small doses to the limit of physical 
tolerance, and phosphorus continuously in small doses 
(t+77 to T ^jy of a grain) are of great service. To obtain sleep 
or quiet delirious excitement, the bromides suggest them- 
selves. These are powerful depressants to functional and 
nutritive activity of nerve-cells, and great harm has often 
been done by their free use in confusional insanity. Opium, 
hyoscine, chloral, and sulphonal are of value, the selection 
of a hypnotic being based chiefly upon the results of experi- 
ment in individual cases. As a calmative, the hot-pack is 
serviceable, and very active delirium has been apparently 
much benefited by free blistering of the scalp. 

VERATRUM VIRIDE IX EXOPHTHALMIC GOlTRE. 

{Ibid.) Patient thirty-five, height above medium, weight 
ninety-three ponnds ; married, mother of three children ; 
anaemic; greatly debilitated; heart apparently much dilated, 
without rhythm, with a wallowing movement ; exophthal- 
mia so great as almost preventing closure of lids ; goitre, 
not measured, but very prominent ; mind deranged; dura- 
tion of malady twelve years. A physician in a distant city, 
the first of man)-, recognized the disease, and advised the 
patient to i eturn home at once, as she was liable to drop 
dead any i..oment. This was confirmed by Dr. W. D. 
Hutchins, of Madison, Ind., who ordered tr. veratrum viride 
three drops, morning and night, to be gradually increased 
to the utmost limit of tolerance. Three drops were barely 
tolerated at first ; four drops produced such weakness that 
the patient was obliged to stay in bed for a short time. 



PERISCOPE. IO5 

Later, twelve drops were taken, night and morning, with- 
out inconvenience, this dose being continued twice daily for 
a year, then dropped to one dose daily for a few following 
months. Improvement was gradual but progressive. At 
the expiration of twelve months from the beginning of 
treatment, the goitre, exophthalmia, and the mental symp- 
toms had disappeared. Bodily weight was then 160 pounds. 
There has been no relapse. 

Liegeois ("London Medical Recorder," August 10, 1889) 
speaks highly of veratrum viride in palpitation of the heart, 
due to various causes, especially when of functional origin. 
In palpitation associated with hypertrophy from valvular 
or peripheral lesions, it gives good results. Indications for 
the drug are the following : 

1. Functional palpitatiDn and arythmia, accompanied by 
heightened arterial pressure. 

2. In palpitation and arythmia due to organic valvular 
lesions during the period of hypersystole. 

3. In palpitation and arythmia during the first of the 
so-called arterial or vascular heart-disease. 

Veratrine is irritating and even emeto-cathartic ; vera- 
trum viride has none of these distressing symptoms, and, 
like strophanthus, may be given for weeks together, if 
sufficient interval be allowed to elapse between each dose. 
If the dose be not excessive, no cumulative effect is pro- 
duced and tolerance is not established. 

HYPERPYREXIA IN HYSTERIA. 

The " Therapeutic Gazette," of Dec. 16, 1889, calls 
attention to a notice upon this subject, that appeared earlier 
in a Danish journal, thence assumed a German dress, and then 
found a place in the " Lancet" of Oct. 12, 1889. The 
patient, after an attack of haemoptysis, suffered from severe 
dyspnoea, cyanosis, and temporary asphyxia, several times 
during the night ; after the attack there was loss of con- 
sciousness for some time, anxiety, and inclination to hallu- 
cinations. During the next two months the symptoms were 
repeated without any signs of phthisis. There was reten- 
tion of urine. The temperature varied for three days from 
103° to 104 F. ; on the fourth day, at noon, it rose to 113 
The physician, Lorentzen, found the patient with other 
signs of inflammation ; slightly delirious ; temperature, one 
hour later, 108° ; in the evening, 106. 3 . The next day it 
rose to 1 1 3 , but fell in an hour to 99.5 . It varied in the 
next few days from ioi.3 : to 103. i°, and then became nor- 
mal. Lorentzen considers the rise of temperature and 
respiratory disturbance as purely neuropathic. The aston- 



ro6 PERISCOPE. 

ishing statement is made that Teale found the temperature 
in a hysterical patient 122 . Wunderlich records a case 
where it was 109 4 . 

TRAUMATIC HYSTERIA. 

The " Gazette des H6pitaux,"for Nov. 23, 1889, contains 
an admirable paper with the above title, by M.E. Brissaud. 
Hysteria he considers one and indivisible, whatever the cause 
that fans it into flame, whether traumatism, intoxication, 
lightning, terror, or even misplaced love itself. Xone of 
these are more than exciting causes, quite incapable of 
creating distinct forms of hysteria, and occupying, in the 
nature of things, a subordinate position Accidents and 
profound emotions render certain persons hysterical, be- 
cause they have an hysterical make-up ; but the accident or 
the violent emotion cannot of itself create hysteria. Other- 
wise almost every one would be a victim, for some accident 
happens to even the best of us during the course of a life- 
time ; and it is well known that the men and women of 
keenest intellect and greatest usefulness are capable of the 
most profound emotion. " Passions are the most truly 
creating things in the world, and the want of passion the 
truest death or unmaking of things." Thus, in the normally 
constituted human being, profound emotion brings about 
power, and controlled passion liberty and happiness. Xot 
so with abnormal humans, whether men or women. Emo- 
tion or an injury conquers them ; and the result may be 
disturbances of sensation, hemianesthesia, pharyngeal an- 
aesthesia, disseminated hyperesthesia, concentric restriction 
of the field of vision, dyschromatopsia, various paralyses, 
loss of muscular sense and the power of speech, contrac- 
tures, laryngeal or oesophageal spasm, nervous crises and 
physical symptoms, — in a word, manifestations of hysteria. 
These occur in prisoners, in street-vagrants, in idle, luxuri- 
ous women, in self-indulgent men, in the overworked of 
both sexes, in children sometimes, but only among the 
hysterical. 

The subject of injury, poison, overwork, or emotion 
reacts according to its individual mechanism. An exciting 
cause only is necessary for such reaction. In this resides 
the specific nature of hysteria, for it is in itself almost equal 
to a function, responding to external stimuli. The retina 
has but one method of reaction to irritations, however they 
may be produced, whether by pricking, burning, pinching, 
faradization, etc. The reaction is always a visual sensation. 
This visual sensation is a physiological constant quantity, 
while hysteria is the pathological constant quantity. If 



PERISCOPE. I07 

railway-spine or railway-brain presents the phenomenon of 
hysteria, in what way do they differ from hysteria proper? 
Neurasthenia may be added the other condition (hysteria), 
as it is frequently, but no hybrid disease results, any more 
than when exophthalmic goitre and hysteria co-exist, or 
Addison's disease, or migraine. The two may be combined, 
but never compounded. Vibert says there is no special 
form of general paralysis following an injury. The disease 
acts just as in spontaneous cases. Charcot makes the same 
statement in regard to hysteria. The author objects seri- 
ously to so-called toxic hysterias, for the nervous symptoms 
in cases of poisoning may express themselves in three dis- 
tinct pathogenic forms or stages of special evolution, that 
may or may not be hysteria. In the first, the nervous 
symptoms disappear simultaneously with the general phe- 
nomena of intoxication. They owe their existence to the 
presence of some toxic element, and hysteria is not their 
source. In other cases, as the poison is eliminated, nervous 
manifestations increase ; but alterations in sensibility always 
affect circumscribed territories under such circumstances, 
as the region of a plexus, a nerve-trunk, or its branch. 
Paralysis of motility is accompanied by muscular atrophy 
sometimes, and the reaction of degeneration always. In a 
third order the patient has recovered long ago ; the poison 
has been altogether eliminated ; but the man or woman is 
paralyzed, anaesthetic, with muscular, articular, and cuta- 
neous sensibility deficient or lost and faradic reaction 
normal, and other fymptoms characteristic of true hysteria. 
This is simply the history of an hysterical person who has 
been poisoned, and not the history of any special new 
disease. 

HYDROTHERAPY IX MENTAL DISEASE. 

In the " Bulletin de la Societe de Medecine mentale de 
Belgique" (Dec, 1889) forty-four pages are devoted to a 
study of this subject, by Dr. Jul. Morel. Various forms of 
application for different abnormal states — as neurasthenia, 
epileptic, choreic, or hysterical mania, hystero-epilepsy, 
melancholia, general paresis, etc. — are considered with care 
and precision. The bibliographical index is of value, 
comprising some twenty -eight sources of information. 
Mechanical methods of cure have not as yet received all 
the attention they deserve, it being easier to take some- 
thing than to do something. In the treatment of mental 
and nervous disease there is, without doubt, a brilliant 
future for hydrotherapy. L. F.-B. 



1 08 PERISCOPE. 

GASTRIC NEURASTHENIA AND ITS TREATMENT. 

Prof. Dujardin-Beaumetz, according to the translation 
of E. P. Hurd, M.D. ("Therapeutic Gazette," Jan. 15, 1890), 
after describing a clinical case with marked dilatation of 
stomach, slight enlargement of the liver, and an easily 
manipulated and mobile left kidney, with a history that 
goes back to a distant date of disordered functions of the 
digestive tube, speaks of this class of neurasthenias who 
have dilated stomachs, as numerous, and comprises, in the 
expressive phraseology of Jrastour, the " deseqnilibres dn 
ventre" ("those whose stomachs are not equilibrated"), and 
that they constitute the rank and file of the neurasthenics. 
The author discusses three theories, which have been 
broached to explain these disorders dependent on bad func- 
tionment of the nervous system. 

The nervous theory — so ably defended by Beard — lately 
defended by Leven, who assigned modifications of nerve- 
cells of the solar plexus a preponderant role : " This needs 
an anatomical demonstration more precise than has been 
furnished by Leven." The author also asks : " What causes 
these solar-plexus irritations?" 

The second theory : a more plausible one advanced by 
Glenard, which is, " that all sorts of functional nervous 
derangements included under the head of neurasthenia 
depend on a modification effected in the reciprocal relations 
of the different portions of the intestines" — displacements 
to which is given the name of ptoses, and may pertain to all 
the organs contained in the abdomen. 

Splanchnoptosis (terminology of the Lyons school) is 
seen most frequently in prolapsus of the right flexure of the 
colon and first part of the transverse colon. 

This theory of a fundamental organic lesion of enterop- 
tosis was first made known by Glenard in 1885, and con- 
firmed by many others since. The mobility of the kidneys 
— nephrotosis — is dependent, mechanically, upon the enter- 
optosis. To oppose this is the humoral theory of Bouchard 
— auto-intoxications (from ptomaines, leucomaines, etc.) of 
intestinal origin — which causes congestion of liver — nephro- 
tosis gastrectasis — and a long train of nervous phenomena, 
which are dependent upon the direct irrative action of 
ptomaines on all departments of the organism. 

After comparing these two theories of Glenard and Bou- 
chard, and the inability which either possessed to explain 
all the pathological changes that occurred in true gastric 
neurasthenia — such as dilatation of stomach and enleeble- 
ment of gastric mucoid, which to a great extent must go 



PERISCOPE. 1 09 

back to congenital causes — he regarded that Bouchard's 
theory deserved the most acceptance, and considered the 
pathological condition of the large intestine to vary — some- 
times dilatation of the descending colon — and some patients, 
with all the phenomena of gastric neurasthenia, to have, on 
careful examination, dilatation of the entire colon, and not 
the stomach, and to be treated, not by lavage of the stom- 
ach, but by antiseptic lavage of colon and rectum. 

The author next considered the treatment of Glenard, 
summarized as follows : 

1. To combat the visceral prolapsus and augment the 
abdominal tension by means of an appropriate abdominal 
belt. 

2. To regulate the intestinal evacuations. 

3. To institute a special regimen, in order to strengthen 
the digestive organs. 

The author then considered briefly the importance of 
distinguishing between dilatations of stomach and intes- 
tine ; the most important sign being bruit de clapotement, 
which must be heard below an oblique line which passes 
from borders of the free ribs and the umbilicus. To obtain 
this briiit it is often necessary to resort to overcoming the 
vacuity of the stomach by having the patient drink a glass 
of water, and the effect of contraction of the abdominal 
recti muscles by patient taking a full inspiration and then 
press suddenly upon the abdominal wall, grasping with 
both hands the two sides of the abdomen, etc. Examina- 
tion in iliac fossa will develop the bruit in intestinal dila- 
tation. 

Summary of treatment for gastric neurasthenia is as 
follows : 

"1. The patient may take with each meal five grains 
each of salicylate of bismuth, magnesia, and bicarbonate of 
sodium in capsule. 

" 2. He may take, ongoing to bed, a dessert-spoonful of 
the compound licorice-powder. 

"3. Every day he may have a cold-jet douche, applied 
along the vertebral column. The duration of the douche 
should not exceed fifteen seconds (if the patient be a lady, 
douche the feet with warm water) ; energetic dry friction 
with a flesh-brush after the douche. 

" 4. Walks in the open air, muscular exercises (opposi- 
tion gymnastics, fencing, etc.) are beneficial. 

" 5. Pursue with rigorousness the following dietetic regi- 
men : Let there be seven hours at least between the two 
principal meals. If the patient takes three meals a day, the 
first should be had at 7.30 A. M., the second at 1 1 A. M., the 



I I O PERISCOPE. 

third at 7.30 P. M. If two meals only should be eaten, let 
the first be at 10 A. M. and the second at 7 P. M. Never to- 
eat or drink between meals. 

" Let the diet consist largely of eggs, cereals, starchy 
foods generally, green vegetables, and fruits. 

" a. The eggs to be but little cooked (creams, cus- 
tards). 

" b. The starchy foods to be thoroughly cooked (mashed 
potatoes, stewed beans, lentils, revalesciere, racahout, lac- 
tated farina, panada, rice in all its forms, macaroni, biscuits, 
buns, hominy, oatmeal, etc.). 

" c. The vegetables should also be well cooked (boiled, 
mashed carrots, turnips, peas, cooked salads, spinach, 
etc.). 

" d. The fruits should be stewed, with the exception of 
strawberries and grapes. 

" Use toasted bread instead of plain bread. Eschew 
from the dietary, game, fish, mollusks, crustaceans, old 
cheese, as well as liquid foods, and soups that are too 
thin. 

" To be permitted : soups that have been thickened, 
gruels of various cereals, wheat, rice, Indian corn, etc. 

" As for drinks, take only a tumblerful and a half of a 
mixture of light white wine with ordinary water or Alet 
water ; no gaseous waters ; no pure wine ; no whiskey or 
other distilled liquid. 

" You see the important part played by diet, and espe- 
cially the vegetarian diet, in the treatment of gastrec- 
tasia." 

Criminal Responsibility in Narcomania. By Norman 
Kerr, M.D., F.L.S. (" Medico -Legal Journal," Dec, 
1889). 

" In insanity it is now generally conceded that there is 
a lesion of the brain, though this cannot always be de- 
tected on a post-mortem examination. There is now as 
much evidence to show that there is a brain lesion m in- 
ebriety, that diseased condition which I have ventured 
to call narcomania (a mania for intoxication by any an- 
aesthetic narcotic). In acute mania, as in delirium tremens, 
this lesion is usually quickly repaired. In some lorms of 
mental unsoundness and of narcomania, this lesion is so 
persistent that a prolonged course of treatment is required, 
while in a sensible proportion of cases the lesion is practi- 
cally irreparable. 



PERISCOPE. I J i 

" In the interests of justice as well as in fairness to the 
accused, in all cases of alleged criminal offences com- 
mitted either while under the influence of an alcoholic or 
other anaesthetic, or by a known inebriate in a non- 
narcotic interval, there ought to be a skilled inquiry into 
the previous health-history and heredity of the panel at 
the bar." 

A Contribution to the Study of Exophthalmic 

GOITRE. By Gramme M. Hammond, M.D. (" New York 

Med. Jour.," Jan. 25, 1890). 

After drawing attention to the fact of there having been 
very little advancement of original research in the pathol- 
ogy of the disease, the author drew especial attention to a 
symptom which deserves confirmation from others. This 
he called, from its first observer's name, " Dr. Louis Bry- 
son's symptom," which consists in the inability of the 
patient under forced inspiration to expand the chest up to 
the normal extent. In every case examined this was con- 
firmed. In some the loss of power to expand the chest was 
remarkable, and according to Dr. Bryson, when the expan- 
sion is reduced to half an inch or less, the termination of 
the case is invariably fatal, and was substantiated by Dr. 
Hammond in one case. In eight cases that recovered, the 
power^of the chest-expansion was restored. 

He refutes the theory that disease of the cervical sympa- 
thetic causes the disease, and considered the theory of a 
central lesion " to a circumscribed lesion affecting the vagus 
nucleus, vaso-motor nucleus, and the respiratory nucleus" 
more tenable, and supported by the case of Dr. W. Hale 
White, who " reported a case where the sympathetic was 
found to be healthy. A series of sections were made from 
the lowest part of the medulla to the corpora quadrigemina. 
At the level of the lowest part of the olivary nucleus there 
was, just under the posterior surface of the medulla, evi- 
dence of slight inflammation. The next few sections were 
quite healthy, but those in the neighborhood of the sixth 
nerve showed considerable changes. Immediately under 
the posterior surface of the medulla, extending from the 
mesial line as far out as the restiform bodies, which were 
slightly implicated, were numerous haemorrhages. The 
area occupied by these haemorrhages did not extend deeply, 
so that, except for a slight implication of the nerve-cells of 
the sixth nucleus on one side, the nerve-cells had escaped 
injury. The haemorrhages seemed almost entirely limited 
to the posterior part of the formatio reticularis, but there 
were two or three small, deep ones. They were not marked 



112 PERISCOPE. 

at this level, but were observed up to the lower part of the 
aqueduct of Sylvius." 

Dr. White believes this is the first case where organic 
lesions have been discovered in the medulla in exophthal- 
mic goitre, but Lockhart Clark reports a case where the 
" corpora quadrigemina and the medulla, particularly on its 
posterior part, were very soft, and, on minute examination, 
displayed the usual appearance of common softening." 

Fox states that " the weak point in this theory of 
central origin seems to be that there is so seldom any dila- 
tation of other vessels besides the thyreoidal." There is a 
strong probability that there is a general dilatation of the 
blood-vessels. It has been conclusively shown that in 
exophthalmic goitre the electrical resistance of the patient 
is very much diminished below the normal point. And 
although as yet there is no absolute proof, it seems plausible 
and probable that a general dilated condition of the vessels 
would account for the greatly diminished electrical resist- 
ance. 

In many instances no lesion has been discovered at all, 
and the burden of proof goes to show that exophthalmic 
goitre is frequently a reflex neurosis. 

Those cases reported the reflex disturbances as situated 
within the nasal cavity. The author considered irritation 
in other parts of the body might do the same, perhaps more 
liable parts being the eyes, nasal cavity, and genito-urinary 
apparatus. 

Dr. Hammond confined the discussion of the treatment 
principally upon the consideration of carbozotate of ammo- 
nium, the value of which in the treatment of exophthalmic 
goitre was first discovered by Dr. A. C. Combes, his clinical 
assistant, and finally says : 

" I have used it on three cases of my own, with, I think, 
decidedly good results. Its use is, however, limited, and 
for reasons which I will now mention cannot be given 
indefinitely. 

" Following the directions of Dr. Combes, I have given 
the remedy in pill-form (each pill containing one grain of 
the drug), three times a day for the first week. In the 
second week two pills three times a day are given, and, if 
it can be borne, three pills three times a day in the third 
week. The physiological effects of the drug are very 
decided. They were observed by Dr. Combes, and his 
observations have been verified by my own. At about the 
end of the first week the skin and conjunctivae assume a 
slight saffron color, which deepens if the drug is persisted 
in. Then a peculiarly unpleasant odor emanates from the 



PERISCOPE. I i 3 

body, which is identical with that produced by dirty feet, 
and can be distinctly noticed if you approach within six or 
eight feet of the patient. Following this, severe gastric dis- 
turbances show themselves. It is rarely possible that 
patients can take this remedy longer than three weeks, but 
while they take it the effects upon the heart, the respiratory 
tract, and the exophthalmia are undoubted." 

A CASE OF CEREBROSPINAL MENINGITIS. 

Dr. J. F. Erchnann, in the same number of the " New 
York Med. Jour.," reports a case of cerebro-spinal menin- 
gitis with remarkable diminution of number of respirations. 
On the seventh day the number of respirations had fallen 
to four in a minute A hypodermic of one-fiftieth grain of 
sulphate of atropia was administered, and within three hours 
the average respirations per minute were nine. They were 
averaging six the next day ; the following day thirteen. 
Sulphate of atropia was the drug used to combat this symp- 
tom. Case recovered. 

" Leyden attributes the diminished and Cheyne-Stokes 
respirations observed in the late stages of this disease to 
pressure upon the medulla produced by oedema, basing his 
opinion on the observations of SchifT after the artificial 
induction of haemorrhage in the vicinity of the medulla in 
dogs." C. H. B. 

ON ALIMENTARY THERAPY IN THE TREATMENT OF 
MENTAL DISEASES. 

Lattier (" Ueber alimentare Therapie bei Behandlung 
der Geisteskranken," in " Centralblatt fur Nervenheilkunde, 
Psychiatrie und gerichtliche Psychopathologie," xii., 20, 
1889) distinguishes, in the alimentation of patients suffering 
from mental diseases, those which are only cared for and 
those which are actively occupied, who need more nutri- 
tious food, which must contain a greater amount of nitroge- 
nous constituents. The proportion for those who are only 
cared for he determines, according to Gasparin, 264 grammes 
of carbon and 12 grammes of nitrogen as sufficient; while 
for those patients who also work he recommends 309 
grammes of carbon and 25 grammes of nitrogen. 

He especially investigated the peptones. The pepton- 
izing is caused through the action of the gastric juice and 
the secretion of the pancreas. The same property is pos- 
sessed by carix papaya, which is frequently employed. In 
the nutrition of a man Lattier assumes 1 grm. of peptone to 
1 kilogrm. of the body-weight, but considers the liquid 
peptones superior to the dry ones, because the former are 



I 1 4 PERISCOPE. 

much more readily taken. They may be prepared in bouil- 
lon or wine if they have to be given by the oesophageal 
sound or per rectum. 

200 grms. of dry peptone may be obtained from 1 kilogrm. 
of meat. The following formula is recommended : 

Malaga, - - - - - - -25 grms. 

Dry peptone, - - - - - -5" 

As regards the employment of raw meat, this was given 
with great result in the Quatre-Meres Institution, for the 
last fifteen years, in the following preparation : 

Raw scraped meat, - 100 grms. 

Powdered sugar, - - - - - 40 " 

Wine, - 20 " 

Tinct. cinnam., - - - - 5 " 

The mixing is done in a mortar with addition of the 
liquid. A pap is formed, which is readily taken by the 
patient if prepared on bread like a sandwich. 

Lattier attaches great importance to the use of pulver- 
ized meat, which possesses the same nutritive properties as 
bread with bouillon, although not the same as raw meat, as 
was shown by the experiments on animals. It may be 
administered once or several times a day, in doses from 
50 grms. to 300 grms. To facilitate the ingestion and pre- 
vent the remaining of it in the mouth, the following formula 
is recommended : 

Potato-flour {poudre), 5 grms. 

Pulverized meat, - 50-100 " 

Water or bouillon, - 200-400 " 

Salt or tinct. of cloves, - - - q. s. 
The whole mixture is boiled, with continuous stirring ; 
the semi-fluid preparation is easily taken. 

Kefir is considered superior to koumyss, because the 
former possesses an agreeable taste and really nutritive 
properties. Its preparation takes place by the action of a 
peculiar mushroom, which grows in the Caucasus, and which 
causes spirituous fermentation. It is a somewhat thick 
liquid, of a milk-color, and of a somewhat acid and peculiar 
taste. The chemical combinations of milk, kefir, and kou- 
myss are given comparatively : 





MILK. 


KEFIR. 


KOUMYSS. 




(Sp. gr. 10.28.) 


(2 days old.) 




1st contains albuminoid constit, - 48 


38 


1 1.2 


2d 


fat, ------ 38 


20 


20.5 


3d 


water and salts, - - 873 


9O5 


918.3 


4th 


alcohol, - - - - — 


8 


16 


5th 


lactic acid, - - - - — 


9 


11. 5 


6th 


lactose (milk-sugar),- 41 


20 


22 



PERISCOPE. I I 5 

According to the above table, kefir contains much more 
albumen than koumyss, less alcohol, and has a less harsh 
taste. Lattier thinks that koumyss as a nutriment contains 
too much alcohol. 

The varieties of milk set in fermentation are especially 
appropriate for alcohol-drinkers, as they elevate the tonic 
and digestive action 01 the milk by their containing alcohol 
and lactic acid. They have shown themselves to be very 
efficacious as medicaments and nutriments. 

In the nutrition of insane patients who defy the taking 
of food and are to be fed through the oesophageal sound, it 
must be remembered that the supply should be a more 
abundant one than in sane patients, because the tissue-waste 
is a more extensive one. Lattier found this confirmed by 
chemical experiments, especially in patients who were suf- 
fering from melancholia activa. Hence are to be especially 
recommended fats, as they diminish the waste of albumen, 
in combination with eggs, meat, bouillon, etc. He recom- 
mends for feeding with the sound the following formula : 

NITROGEN. CARBON. 

4 eggs, weighing 2i6grms., - 4.ugrms. 32.40 grms. 

2 litres of milk, ----- 13.20 " 160 
Bordeaux wine, 215 grms., - 0.04 " 10 

Pulverized meat, - - - - 3.91 " H-32 " 



21.26 " 216.72 " 

The nutrition by peptonic injections, per rectum, of those 
patients with whom the introduction of the oesophageal 
sound is impossible, is especially considered and thought 
very well serving the purpose. Although they cannot be 
continued for any length of time, they are yet of great 
value for a certain time. Before the application of the same 
an ordinary injection is recommended, to which a few drops 
of tinct. opii are added in order to weaken the contractions 
of the rectum. Lattier recommends, according to his own 
experience, the following formula : 

Dry peptone, 3 teaspoonfuls. 

Yolk of egg, - - - 1. 

Milk, - - - - - - 125 grms. 

Tinct. opii, ----- 5 drops. 

Pulver. amidon. - - - - 5 grms. 

The addition of amidon is said to render it more easily. 

P. and P. (Boston). 



Society Reports. 



PHILADELPHIA NEUROLOGICAL SOCIETY. 

Stated Meeting, November 25, i88g. 

The Vice-President, Dr. WHARTON SlXKLER, in the 
chair. 

Dr. CLARKE, resident physician at the Philadelphia 
Hospital, presented to the Society a patient suffering from 

MERCURIAL TREMOR. 

The patient was in Dr. Dercum's wards, temporarily in 
charge of Dr. Mills. The following are the notes of the 
case from the records of the hospital. 

J. K., aged eighteen, single, had been working for a 
large Philadelphia hat manufacturer for two years and a 
half. He handled the "fur" used in making felt, and 
worked in an atmosphere full of the dust from this fur. He 
was well until seven months ago, when a tremor developed 
in his hands. This has increased and extended to his legs, 
tongue and lips. For this "nervousness" he went to the 
hospital, December 19, 1889. 

His intellect seems good, although he states that his 
memory has failed in the last few months. He has no pain 
or headache, sleeps well, and does not seem emotional. 
His powers of co-ordination are unimpaired, and he has no 
paralysis. He is fairly well nourished, but anaemic and 
weaker than he was some months ago. The dynamometer 
records sixty-five for each hand. The legs are somewhat 
spastic, or perhaps exhibit a pseudo-spasticity. Knee-jerk 
is present in both limbs, but sometimes seems to be absent 
because of the forced position of flexion in which the legs 
are held. There is no true ankle clonus, but examination 
for clonus throws the limbs into violent vibration. 

The tremor affects all parts of the body. It is most 
marked in the hands where it first started. When he holds 
the arm extended the whole limb is affected by a general 
vibration, most positive at the wrist. The hand tends to 
assume a slight extension at the wrist, and a slight flexion 
at the metacarpo-phalangeal articulation. There is a tremor 
of the head and trunk and also of the tongue. The articu- 



SOCIETY REPORTS. \\-j 

laris of the eye is thrown into irregular spasm during the 
examination of that organ. The tremor is coarse, affecting 
different parts of the body coincidently, but in a different 
degree ; it is increased on voluntary motion ; if the limbs 
are handled abruptly the tremor is so much increased as to 
resemble a case of paramyclonus. At times he has the 
appearance of a person in a severe fit of the ague. 

At some of the examinations made of this patient there 
appeared to be losses of sensation ; with the aethesiometer 
he was unable to distinguish two points in the forehead at 
two centimetres distance ; he did not complain of quite severe 
prickings with a needle. His speech is of a tremulous, 
slightly feeble character. His gait is not much affected. 
His pupils respond to the light, and the special senses are 
not impaired. His pulse is usually about 72, and there is 
no palpitation of the heart. 

Three months after the beginning of the tremor, his 
gums became red and sore, but there was no increase of the 
flow of saliva, and his teeth were not loose. He had neither 
diarrhoea nor constipation. After a time the redness of the 
gums disappeared. 

Dr. MILLS spoke of the rarity, in his own experience at 
least, of mercurial tremor. He also discussed the peculiari- 
ties of the tremor as exhibited by this patient. In the 
wards for nervous diseases of the Philadelphia Hospital, he 
had at the same time, besides this case of mecurial tremor, 
patients exhibiting the tremulous phenomena of alcohol 
and lead poisoning, of paralysis agitans, disseminated 
sclerosis, and paretic dementia, as well as cases of ordinary 
chorea, Huntingdon's chorea, and paramyoclonus. The 
tremor seemed to resemble most that present in some cases 
of disseminated sclerosis, although the patient's tr-emulous, 
enfeebled speech was perhaps more like that observed in 
dementia paralytica. On exciting or handling the patient 
the trembling increased and spread, much as in reported 
cases of paramyoclonus. Gowers says that the symptoms 
often resemble those of general paralysis of the insane more 
than any other disease, but the preponderant tremor, in- 
equality of pupil, optimism, and indications of spinal 
degeneration are absent. 

Gowers gives the following description of mercurial 
tremor which, it will be seen, closely corresponds with the 
account of this patient: 

"A peculiar tremor, known among workmen as the 
'trembles,' and medically as 'mercurial tremor,' is the most 
common and characteristic symptom. It is at first occa- 



I I S SOCIE TV REPOR 7 X 

sional, occurring only when the patient is excited, and it is 
always increased by emotion. It usually begins in the face 
and tongue, and then invades the arms, and afterwards the 
legs. At first the tremor occurs only on movement, but 
ultimately it may become constant. In the former case the 
condition of the patient resembles that of one suffering from 
disseminated sclerosis, except that the tremor is less wide 
and less irregular than in characteristic cases of the latter 
disease. When constant, the tremor resembles that of 
paralysis agitans. During sleep the tremor usually ceases, 
but in extreme cases may only lessen. It interferes much 
with articulation, rendering the speech stammering and 
hesitating. When considerable, it may render the move- 
ment of the arms so unsteady that the patient cannot feed 
himself, and his gait becomes affected. At first the limbs 
are strong, but after a time muscular power is impaired, 
sometimes more in one limb than in another, but it rarely 
progresses to complete loss. Reflex action and power over 
the sphincters are always impaired, and electric irritability 
of the muscles is normal throughout. 

"Psychical symptoms are also common, and may pre- 
cede the tremor. They have been very carefully studied 
by Kussmaul. Irritability and a difficulty in giving atten- 
tion to a subject are often the first symptoms, and may be 
accompanied by considerable mental distress and sleepless- 
ness. Hallucinations sometimes occur, and there may even 
be outbreaks of maniacal excitement, but the insanty rarely 
corresponds to any distinct variety. This condition has 
been termed 'mercurial erythism.' It is sometimes accom- 
panied by headache and palpitation of the heart. 

"Sensory symptoms are present in many cases; pains, 
especially in the region of the fifth nerve and in the joints ; 
formication in the limbs, and even loss of sensibility to 
pain ; paroxysms of distressing sensations in the thorax, 
resembling those of asthma. The sensory disturbances 
always augment the mental instability. In rare cases more 
grave cerebral symptoms occur — considerable hemiplegic 
weakness, aphasia and deafness." 

Dr. GEORGE E. de Schweinitz. — Mercury manifests 
poisonous symptoms independently of acute toxaemia the 
result of injection of a soluble salt, by the appearance of 
the ordinary stomatitis (ptyalism); in tremor and allied 
nervous manifestations; or as "mercurial cachexia." Dr. 
H. C. Wood, in his lectures in the University of Pennsyl- 
vania, has long taught that if the metal is introduced by 
inhalation, tremor or similar phenomena result; if by the 



SOCIETY REPORTS. I 19 

mouth or through inunction, stomatitis ; and, in the absence 
the elimination through iodide of potash, "mercurial 
cachexia." 



Stated Meeting, December 23, 1889. 

Dr. James Hendrie Lloyd in the chair. 

Dr. Ross R. BUNTING read a paper on " Paralysis of the 
Serratus Magnus." (See page 6j.) 

DISCUSSION. 

Dr. Charles K. Mills. — I remember only one case of 
this kind, and that was seen at the University Hospital 
Dispensary some years ago. The diagnosis of paralysis of 
the serratus magnus muscle is not difficult if the paralysis 
be limited to that muscle and ine case is carefully studied. 
Several conditions at first sight might be mistaken for this 
paralysis. The appearance of the scapula is not unlike 
that seen in some cases of rotatory lateral curvature of the 
spine. The test in such cases is of course to have the 
patient attempt to perform the physiological actions of the 
muscle. I have recently seen two cases in which the 
appearance of the shoulder when at rest was similar to that 
shown in the photographs. One was a case of rotatory 
lateral curvature ; the other was a case of considerable lop- 
sidedness, with some curvature and wasting of muscles. 
It is stated that dislocation of the fibres of the latissimus 
dorsi passing over the point of the scapula sometimes occurs 
and causes a somewhat similar deformity. 

The next paper presented was by Dr. M. Imogene 
BASSETTE on " Two Cases of Paralysis occurring during 
the Puerperal State." (See page 93.) 

DISCUSSION. 

Dr. Francis X. DERCUM. — I entirely agree with Dr. 
Bassette in regard to the organic nature of the affection 
and its probable association with occlusion of the blood- 
vessels from some morbid change, septic or otherwise, in 
the blood. It is difficult, indeed, to form any other hypoth- 
esis for these cases. 

Dr. Charles K. Mills. — I should like to Hear some 
discussion in regard to the cause of this condition in cases 
without heart-disease. The question arises whether or not 



I 20 SOCIE TY REPOR TS. 

it might not occur from embolism as a result of phlebitis. 
In the first case reported to-night there were no acute 
symptoms, no pain, and no local symptoms. The second 
case might be of septic origin — the patient having had a 
sudden chill, followed by paralysis. 

Dr. James Hendrie Lloyd. — I have studied this sub- 
ject in the preparation of the paper referred to by Dr. Bas- 
sette, and I can see no reason why we should try to find a 
special name or erect a special pathology for these cases of 
organic hemiplegia following labor. Dr. Mills suggests the 
possibility of embolism. Hemiplegia occurring during the 
puerperium, as the result of embolism from affection of the 
heart, is simply a coincidence of the labor. The indications 
are that these cases reported by Dr. Bassette are organic, 
but whether they are embolic or haemorrhagic it is difficult 
to say. We have not the grounds to differentiate between 
these two accidents. Whether or not they are due to 
special conditions of the puerperal state, such as sepsis, 
could only be determined by a study of the pathological 
conditions in this state. If the woman were septic, we 
might suppose that there was thrombosis of embolism. 

Dr. H. A. Tomlinson read a paper on a " Case of Acute 
Melancholia during the Progress of which there appeared 
' Argyle-Robertson' Pupil, with Abolished Patellar Reflexes 
on One Side and much diminished on the Other." 

DISCUSSION. 

Dr. Charles K. Mills. — The most remarkable features 
in this case were the presence and disappearance of the 
Argyle-Robertson pupil and the absence and reappearance 
of the knee-jerk. We have been in the habit of regarding 
these two symptoms as of vital importance in making a 
diagnosis of incurable mental affection. They are of par- 
ticular importance in making the diagnosis of paretic 
dementia, whether it be of the spinal form or of the more 
ordinary type. The mental symptoms in the case reported 
are certainly not those of paretic dementia, although in 
paretic dementia there is often a long stage of depression, 
from which the patient may rally, to sink again. 

Dr. J. Madison Taylor. — In regard to the appearance 
and disappearance of the knee-jerk, I would say that we 
cannot now attach as much significance to this sign as did 
the older writers. In the recent researches made by Dr. 
Mitchell, and in which I largely assisted, great variations 
were found in the knee-jerk in presumably healthy indi- 



SOCIETY REPORTS. 121 

viduals. In some individuals it would' sometimes disap- 
pear, while in the same persons at other times it would be 
immensely increased. The variations in the knee-jerk 
would seem to have more to do with varying states of nerve 
wave or impulse or whatever it may be that varies in the 
economy. 

Dr. James Hexdrie Lloyd. — There are aberrant forms 
of general paresis where we do have prolonged melancho- 
liac states. I have now under my care a gentleman who 
for months has been in a state of melancholia, and who has 
had no true expansive delusions. 

In reference to the knee-jerk, I may state that I have 
under observation a case of general paresis in which there 
is exaggerated reflex on one side and complete or almost 
complete abolition on the other. 

Dr. George E. de Schweixitz. — I would ask whether 
in this case the fields of vision were taken. 

Dr. Tomlixsox. — They were not. 

Dr. de Schweixitz. — It is excessively difficult in these 
cases of narrow pupil, especially if there is a high error of 
refraction, and more particularly mixed astigmatism, as was 
the case in the patient reported, to determine whether or 
not there are changes in the optic nerve. I do not believe 
that the ophthalmoscope alone is always able to accomplish 
this. A careful study of the color-fields is necessary to 
ascertain slight changes in the papilla, especially if these 
exist in the deeper layer, the surface still being capillary. 

Dr. Charles A. Oliver. — It seems to me that the eye- 
symptoms in Dr. Tomlinson's case point very much toward 
general paresis in its early stages. I have seen quite a 
number of such cases at the State Hospital for the Insane 
at Xorristown, where there has been more or less marked 
change in the optic nerve, as shown by the ophthalmoscope, 
and where, although it was impossible to get the fields of 
vision properly, yet it was determined in some cases that 
there were contracted fields. In these instances I have 
seen from time to time, at intervals of two to six weeks, 
marked changes in the size of the pupil, their relative 
shapes, and the degree of motility of the two irides. As 
these cases advance into the third stage of the disease, there 
is a marked lessening of the motor actions in absolute rela- 
tionship with the amount of change in the optic nerve, 
objectively visible. 

Dr. H. A. Tomlixsox. — I would merely state that Dr. 
Risley, who corrected the error of refraction, examined the 
eve-grounds carefullv, and found no change. 



I 2 2 SOCIETY REPOR TS. 

Stated Meeting \ January 2j, i8go. 
The President, Dr. H. C. WOOD, in the chair. 

Dr. James Hendrie Lloyd exhibited a specimen show- 
ing anomalous distribution of the arteries forming the Circle 
of Willis. 

Dr. JOHN B. Deaver read a paper on "Trephining for 
Extra-Dural Haemorrhage." (See page 83.) 

Dr. J. L. Bower read "Notes on Some Cases of Chorea 
and Tremor." (From Service of Dr. Mills at Philadelphia 
Hospital.) 

Dr. Clara Alexander presented a specimen of "Lep- 
tomeningitis," with the following notes : 

M. M., white, aged fifty-five, an ironworker, was a heavy 
drinker, but had no venereal history. 

Two months before admission to the hospital he slipped 
and fell, striking his head on the curbstone. After this he 
complained of pain in one ear and never seemed to be quite 
well. He was spiritless, but continued his work. About 
one week before coming under observation he began to 
have frontal headache, the pain being very sharp. He had 
chills followed by fever, and pain across the front of the 
chest and stomach. After this there was no recurrence of 
the chill or fever. He had had a cough for about twenty 
years, always worse in Winter. There was no increase of 
the cough and expectoration after the occurrence of the 
chill, but the headache still continued, and he complained 
of pains all through his body. He was anaemic, his heart 
action feeble, but showed no evidence of cardiac disease 
Examination of his lungs proved negative. His conversa- 
tion was perfectly rational. About twenty-four hours after 
admission his condition entirely changed ; he became deli- 
rious, walked in a tottering, feeble manner until he was put 
to bed. Temperature 101 ; pulse 62 ; respirations 30. The 
next day his temperature fell to 97.4 ; pulse 90 ; respirations 
40. Examination of his urine was negative. No paralysis 
could be made out ; his pupils were equal and responded 
both to light and accommodation. He soon sank into a 
condition of coma and died. His temperature again became 
elevated, reaching 105 before death. 

Autopsy. — Some bands of adhesions were present near 
the base of the left lung, also the same on the right side. 



SOCIE 7 Y RE FOR TS. 1 2 3 

The heart was hypertrophied, and in a slightly atheroma- 
tous condition at the valves, most marked at the aortic 
leaflets. The orifices were dilated, the tricuspid opening 
was markedly so, and fat clots were found in the right auricle. 
The stomach, intestines, and spleen were normal. The 
kidneys were large and congested ; the capsules non- 
adherent. The dura mater was firm and slightly thickened. 
The pia mater was thickened and opaque and of a dirty 
yellowish color. The whole surface of both hemispheres 
was covered with organized lymph, also the base of the 
brain and cerebellum. The pia could be removed without 
much decortication. The lateral ventricles were slightly 
dilated. 



JisgUtiu 2jtotc5. 



THE LUNACY COMMISSION'S REPORT OF THE 
STATE OF NEW YORK. 

The first report of the new State Commission in Lunacy, 
which succeeded to the powers and duties of the State 
Board of Charities in respect to the insane, and of the 
former single Commissioner in Lunacy, which was recently 
presented to the Legislature, is a document of unusual 
interest and importance, since it deals with live questions 
of great moment to the people, and especially to the medi- 
cal profession, of the State. Especially will its treatment 
of the subject of State care for the insane, to a discussion of 
which the major part of the report is devoted, attract wide 
attention and pfoduce a lasting effect. 

It classifies and enumerates the institutions wherein 
insane persons are kept ; sets forth the scope of the Com- 
mission's work as prescribed in the act creating it (Chap. 
283. Laws of 1889), and briefly, but with sufficient fullness, 
discusses these copies : Registration of the Insane, State 
Asylums, Revision of Statutes Relating to Insane, Official 
Responsibility, Private Patients, Discharge of Insane from 
Custody, Laws Relating to Chronic Insane, Transfer of the 
Insane, Removal of the Insane from their Homes to Asy- 
lums, Service of Legal Papers on the Insane, Discharge of 
Public Patients on Bonds, Habeas Corpus, Insane State 
Paupers. It then takes up the theme of State Supervision 
of the Insane, and recognizing its paramount place in the 
present bent of the public mind concerning insanity as a 
practical matter of State concern, it occupies some fifty 
pages with a full and explicit exposition of facts, views and 
opinions relating to the question at issue between the 
exclusive care by the State of all its insane on the one 
hand and what is called the "mixed system" of State and 
County care on the other. After adverting to the nature 
and. gravity of the issue and the need of some fixed and 
permanent policy, the Commission gives some pages to 
considerations which it thinks properly precede any rational 
discussion of the matter. These are grouped under three 
main heads, viz.: 1st, the fact that insanity is a disease 
needing treatment; 2d, the error, almost universal half a 



ASYL UM NO TES. I 2 5 

century ago and still common, that there is a hard and fast 
line of distinction between "acute " and "chronic" insanity- 
justifying the belief that all or nearly all cases of the latter 
type are hopelessly incurable ; and 3d, the wrong, unjust 
and injurious idea that those of the insane who are cared 
for at public expense are "paupers" in any true sense of 
the term, and ought not to be treated on any better footing 
than sane "paupers." It reviews the progress of efforts in 
this State to alleviate the condition of the insane, quoting 
from the act establishing the State Asylum at Utica in 
1843, which forbade the counties (except New York, Kings 
and Monroe) from caring for their acute insane ; and then, 
after showing the steps that led to its enactment, citing 
part of the Willard Asylum Act in 1865, which forbade the 
counties fwith the same exceptions) from caring for their 
chronic insane. Their definite declaration of the State's 
purpose to care for all its insane has never been withdrawn, 
but, as a temporary expedient, forced upon the Legislature 
by the imperative necessities of the case. In 1871, power 
was given the State Board of Charities to exempt counties 
which in its judgment had sufficient facilities for caring for 
their own insane. This power has been exercised in behalf 
of nineteen counties, and one (Clinton) was exempted by 
special act. On October 1, 1889, there were 5,371 of these 
so-called "chronic" insane — 3,138 in State asylums, 1,848 
in exempt county poor-houses, and 385 in non-exempt 
county poor-houses. After discussing what should be 
regarded as essential requirements in any proper system of 
care for the insane, the following are presented as the lead- 
ing points of advantage claimed for it by advocates of 
*' county care:" 

That the "chronic" insane being "paupers" and incur- 
able, the lowest rate at which they can be comfortably fed, 
clothed, warmed, etc., is jnstifiable. 2. That they should 
be kept in the county of their residence, to have the benefit 
of visits from relatives and friends. 3. That they are better 
off in the county poor-houses, because land there is usually 
cheap and fertile, and they can be profitably employed in 
tilling it. 4. That better results may be looked for in small 
than in large institutions. The question whether these 
claims are sustained in actual results as observed by the 
Commission is treated exhaustively, and the verdict is 
emphatically in the negative. The several features of care 
that are nowadays regarded as essential in the proper treat- 
ment of insanity are reviewed, and in nearly every one it is 
declared that the county institutions fall lamentably below 
the reasonable standard that should be maintained. Some 



126 ASYL UM NO TES. 

striking, indeed shocking, instances are related of gross 
neglect and disregard of common decency and humanity : 
for instance, putting two filthy patients in one bed, bathing 
three or four patients in one water, sending out a debilitated 
man in chains to work in the fields, the care of insane 
women by male attendants, etc., and other like examples 
of flagrant impropriety, to speak mildly. Respecting the 
relative cost of the two systems, the actual difference is 
believed to be small ; while if equipment, facilities, attend- 
ants, medical supervision, etc., were required of county 
poor-houses in degree equal or approaching to those sup- 
plied at State asylums, the cost in the former would mate- 
rially exceed that in the latter. The Commission recom- 
mend : ist. That all the insane except in New York and 
Kings Counties be transferred to State asylums as soon as 
practicable. 2d. That districts based on proximity and 
population be assigned to each asylum. 3d. That inexpen- 
sive buildings be erected, at a cost not exceeding $550 per 
patient, on the asylum grounds of the present State asy- 
lums. 4th. That the State pay all expense of maintenance 
and removal. 5th. That the Legislature appropriate money 
at its present session to begin the erection ot such build- 
ings. 

The increase of insanity and necessity of additional 
provision for idiots of the unteachable class are briefly 
referred to, and various recommendations are made. 

The number of insane in custody on the first day of 
October, 1889, was as follows: 

State asylums, ----- 5>44 2 

Counties of New York, Kings, and Monroe, - 6,970 

Exempted counties, - 1,848 

Non-exempted counties, - 385 

City alms-houses, - 6 

Quasi-public, ----- 541 

Private asylums, - - 3 ! 5 

Total (an increase of 601 for the year), - 1 S>S°7 

State Asylum for Idiots, - 477 

Custodial Asylum for Feeble-Minded Women, - 250 

The aggregate population, of the foregoing is 15,507 
insane, 477 idiots, 250 feeble-minded women. 

The discussion of the question of State supervision of 
the insane concludes as follows : 



A S YL UM NO TES. I 2 7 

"The conclusion of the Commission regarding the sys- 
tem of county care of the insane is, that however feasible in 
theory, in practical operation it has been found to have 
failed and fallen far short of the hope entertained for it 
when the act of 1871, sanctioning its trial, was passed. As 
a system it has developed inherent difficulties and defects 
which seem to be ineradicable, and which make its success- 
ful operation in all essential respects impossible. Such 
being the case, it ought to be abolished and the policy of 
State care for all of the insane, both chronic and acute, 
should be re-established at the earliest practicable date. It 
can not be said that the system of county care has not had 
a fair trial. It has been in vogue since 1871 under excep- 
tionally advantageous circumstances. During all that time 
it has had the advantages of State sapervision, and yet it 
has failed to meet every reasonable or just expectation. If 
the system has been a failure for nearly twenty years, is it 
not reasonable to conclude that it is likely to be a failure 
for all time to come. It is not claimed that the system of 
State care as now conducted is perfect, but it is steadily 
progressive ; it is humanely and intelligently administered ; 
it represents all that is best in the present state of medical 
knowledge ; and whatever other criticism may be passed 
upon it, it certainly can not be said that the inmates of the 
State asylums are not comfortably housed, sufficiently clad, 
properly fed, provided with sufficient attendance and care, 
and given medical supervision and treatment of an excep- 
tionally high order." 

The report is signed by Carlos F. MacDonald, M.D., 
Chairman ; Goodwin Brown and Henry A. Reeves, Com- 
missioners. 



A RESOLUTION RECENTLY PASSED BY THE 

NEW YORK STATE COMMISSIONERS 

OF LUNACY 

"Resolved, That hereafter no license for the establishment 
and keeping of an asylum for the care, custody or treat- 
ment of the insane or persons of unsound mind, for com- 
pensation or hire, shall be granted except to a duly qualified 
medical practitioner of recognized professional skill and 
standing, who is a graduate of a legally incorporated medi- 
cal college, and has had actual experience in the care and 
treatment of the insane." 



IXjew Instruments. 



AN IMPROVED TAPE-MEASURE. 



By WILLIAM C. KRAUSS, M.D., 

BUFFALO, N. Y. 

Among neurologists perhaps no symptom is more im- 
portant and significant than muscular atrophy or wasting. 
The keynote of diseases affecting the anterior columns of 
gray matter and of peripheral nerves, it is often improperly 
noted and erroneously measured. 

The custom of comparing the two sides by sight or by 
touch, in many cases permits of errors which may be of 
serious moment in reaching a diagnosis or prognosis. The 
employment of the ordinary tape-measure, a step approach- 
ing accuracy, also permits of discrepancies. The practice 
of taking measurements at the lower, middle, and upper 
third of the extremities may be sufficiently exact for one 
measurement on one side, but when double measurements 



A3. 




I ! I I I I I I i 



l 




~tt" r 



G TIEMANN & CO. 



are necessary for comparison, or when successive measure- 
ments are required, this mode is also inadequate, inasmuch 
as it is very improbable that the tape will be applied at 
exactly the same place as before. 

To correct this difficulty, Messrs. Geo. Tiemann & Co., 
of New York, have made for me a tape-measure which per- 
mits of the greatest accuracy possible, and the absolute 
exclusion of guess-work in using it. 



NE W INS TR UMENTS. I 2 9 

It is particularly adapted to the measurement of the 
extremities, and consists of a tape (1) thirty-six inches long 
and one-half inch wide. The English scale is graduated 
on one side and the metric scale on the other. The head is 
supplied with a swivel (3), through which passes the free 
end of the tape, permitting of uniform tension, greater accu- 
racy in reading, and of its being held with one hand. 

The second tape (2) is eighteen inches long and one- 
quarter inch wide, and is provided with a sliding head 
through which the first tape passes. This tape is therefore 
at right angles to, and movable upon, the first tape. It is 
also graduated after the English and metric scales. The 
object of this tape is to ascertain at what distance from a 
certain fixed bony point the first tape has been applied, so 
that on succeeding occasions the measurement may be 
taken at the same point. To illustrate: If the tape (1) be 
applied to the arm at a distance of five inches from the 
internal condyle of the humerus (reckoned by means of 
tape 2), it is obvious that, on succeeding occasions or in the 
comparison of the two extremities, the tape (1) must be 
applied at exactly the same point, thus excluding all pos- 
sible chance of error. 

I believe this tape possesses certain points of value to 
neurologists, surgeons, and those intent upon accuracy and 
precision in their observations. 

176 Franklin St. 



ELECTRICAL BATTERIES. 

In the " Electrical World," Nov. 23, 1889, may be noted 
an account of the latest improved physicians' combination 
cabinet battery, of Jerome Kidder Manufacturing Co., of 
this city, a forty-point selector, by which any number of 
cells can be placed in circuit. 

It contains also a faradic combination-coil (with slow 
and fast interrupter), resistance-coils, accurate milli-ampere 
meter, etc., making a most complete instrument for office 
use. 

High commendation is also given to various other bat- 
teries, cautery, and surgical instruments. 

It may be noted that, at the last electrical exhibit of*he 
American Institute Fair, this firm were awarded the medal 
of superiority, which they have regularly received every 
year since 1872. 



NOTICE. 

INVITATION TO THE TENTH INTERNATIONAL MEDICAL 

CONGRESS. 

In accordance with the decision of the Ninth Congress at 
Washington, the Tenth International Medical Congress will 
be held at Berlin from the 4th to the 9th of August, 1890. 

By the delegates of the German Medical Faculties and 
the chief Medical Societies of the German Empire, the 
undersigned have been appointed members of the General 
Committee of Organization. A Special Committee of 
Organization has also been appointed for each of the differ- 
ent sections, to arrange the scientific problems to be dis- 
cussed at the meetings of the respective sections. An 
International Medical and Scientific Exhibition will also be 
held by the Congress. 

We have the honor to inform you of the above decisions, 
and at the same time cordially to invite your attendance at 
the Congress. We should esteem it a favor if you would 
kindly extend this invitation to your friends in medical 
circles, as way may offer. 

Dr. Rudolf Virchow, 

President. 
Dr. von Bergmann, 
Dr. Leyden, 
Dr. Waldeyer, 

Vice - Pres iden ts . 
Dr. Lassar, 

Secretary- General. 

All communications must be directed to the General 
Secretary, Berlin, N. W., Karlstrasse 19. 



VOL. XV. March. 1890. No. 3 

THE 

Journal 

OF 

Nervous and Mental Disease. 



Original ^vtictcs. 



NOTES OX SOME CASES OF CHOREA AND 
TREMOR. 1 

Case I. — Hereditary {Huntington 's) Chorea in a Negro. 
Case II. — Hereditary {Huntington's) Chorea, Apparently 
with A bsence of History of Heredity. Case III — Heredi- 
tary Chorea with History of Chorea in Father and Infant 
Child. Case IV. — Paramyoclonic Chorea, with a History 
of Other Cases in the Same Family. Case V. — Tremor 
of Paralysis Agitans. Case VI. — Tremor of Dissemi- 
nated Sclerosis. Case VII. — Tremor from the Abuse 
of Alcohol and Tobacco. Case VIII. — Diffuse Undula- 
tory Tremor. Case IX. — Diffuse Undulatory Tremor. 

Service of Dr. CHARLES K. MILLS at the Philadelphia Hospital. 
Reported by J. L. BOWER, M.D. Resident Physician. 

IN the Philadelphia Hospital Wards for Nervous Diseases 
are many cases illustrating diverse forms of chorea and 
tremor. Some of these have already been reported ; 
others are examples of types of disease which have been 
so thoroughly studied and recorded that details of them 
would probably not serve a useful purpose ; although 
a complete investigation of all, with sphymographic trac- 
ings, and close descriptions of the peculiarities of move- 
ment, might constitute a valuable contribution. 

1 Presented to the Philadelphia Neurological Society, January 27, 1890. 



I 3 2 CHA RLES K. MILL S. 

Condensed notes will be given of a few cases with brief com- 
ments, particularly directed to the observed peculiarities of 
tremulous or choreiform movements. Of the nine cases 
here reported five have been observed in the Nervous 
Wards of the Philadelphia Hospital ; the other four have 
been furnished me by Dr. Mills, from notes of cases observed 
elsewhere, One of the most interesting of the cases (Case 
IV.) has been in the Hospital for a considerable time and 
has been frequently studied and commented upon by the 
physicians in attendance. Dr. James Hendrie Lloyd gave a 
sketch of this case in a clinical lecture recorded in the 
Medical and Surgical Reporter, May 19, 1888 ; but it is suf- 
ficiently important to call for a more detailed report. Cases 
X. and XI. would seem to be practically undescribed forms 
of fibrillary tremor, as exactly similar cases are not to be 
found in the text-books. Dr. Mills has suggested to desig- 
nate this form of tremulous movement diffuse undidatory 
tremor. The cases of paralysis agitans, disseminated 
sclerosis, and alcoholic tremor are introduced to compare 
the varieties of tremor. 

Case I. — Hereditary (Huntington's) Chorea in a Negro. 

E. H., age 36, barber. His father died of some disease 
unknown to the patient. The disease from which he is suf- 
fering is inherited from his mother ; she with two sisters 
and one brother were or are suffering from the same 
trouble. In his mother the disease developed at the age of 
26 and gradually grew worse until she died at the age of 68 
from exhaustion ; he does not know exactly at what age it 
developed in his aunts and uncle, but thinks that it was 
somewhere between 20 and 35 ; one of the aunts is still liv- 
ing at the age of 50 years, the other is dead ; the uncle is 
42 years of age and in him the arms alone are affected. 

The patient has been a hard drinker ; when 28 years old 
he was drinking heavily and became suddenly paralyzed in 
both lower extremities and remained in this condition for 
three months, when power gradually returned. From 
description the affection does not seem to have been multi- 
ple neuritis, as the paralysis came on suddenly and he had 
no pain. Three years ago he had a venereal sore, probably 
a chancre, followed by a bubo. 

Six years ago he first began to have twitching of the 
hands ; this spread gradually but very slowly, until his 



CHOREA AND TREMOR. I 33 

whole body became affected and his present condition 
reached. When he stands he sways a little from side to side, 
occasionally lifts one or the other foot, raises and depresses his 
shoulders, almost constantly opening and shutting and 
contorting his fingers, at times also thrusting one or both 
hands to his back. He is never entirely still, and he gives 
the impression that he is trying hard but unsuccessfully to 
control his nervousness. When he walks his gait is stiff, 
weak and unwieldy (perhaps in part from the old paralysis). 
The irregular movements in the hands and fingers continue, 
and in the extremities he has occasional swaying and 
pseudo-ataxic movements ; now and then he lifts one foot 
high and balances himself before stepping out. When sit- 
ting down he is still unquiet, but in less degree ; his trunk, 
arms and hands are moving almost continuously, the latter 
being shifted from his knees to his thighs where he places 
them in order to keep them quiet. All his movements con- 
sist of a series of irregular starts affecting one part after 
another or several parts together. At times they have the 
appearance of design, and the patient seems also to be try- 
ing to restrain them. The movements are not increased by 
voluntary efforts, but seem to be by excitement. He writes 
fairly well, but slowly and with difficulty, and it appears to 
be a great effort to keep himself in the proper position and 
direct his movements for writing. His signature is given 
below. 




His speech is slow, and at times he pauses as if to co- 
ordinate the movements of articulation. 

On inquiry it is found that the parents and ancestors of 
the patients were all full blooded negroes. The patient's 
mental condition so far as can be determined, is not 
impaired. His physique is good ; height, five feet nine 
inches ; weight, 130 pounds. His lungs, heart and kidneys 
are normal. 

This case is interesting for several reasons. In the first 
place, it is another illustration of hereditary chorea. Its 
occurrence in a negro adds to the interest, as chorea of any 
type is rare in this race. His case presents points of great 
similarity to that of Miller, a patient in the same wards, 
an account of whose disease and remarkable family history 



134 CHARLES K. MILLS. 

has been given by Dr. Wharton Sinkler, in one of the best 
papers on hereditary chorea. 1 

The next case, so far as the choreiform symptoms are 
concerned, would seem to be best classed as Huntington's 
chorea, but the most careful inquiries, could elicit 
no history of heredity. The patient's mental condition is 
somewhat impaired, but not to a marked extent, and he 
gives a clear history of the absence of nervous disease in 
his family He would be able to recall the striking fact of a 
disease similar to his own having occurred in his family. 
His parents, brothers and sisters, were certainly not so 
affected. 

Case II. — Hereditary (Huntington's) Chorea, apparently 
with absence of history of heredity. 

H. C, age 32, a painter, to the coming on of his present 
disease had excellent health, He is a moderate drinker, and 
denies venereal trouble ; he does not use tobacco. His 
family history is entirely negative. 

About three years ago he began to have pain in the 
right knee which was swollen ; in about a month he re- 
covered from this trouble, but shortly afterwards he 
noticed that his hands and his fingers were weak, 
and sometimes trembled or twitched ; his legs and head 
also became affected about three months after his upper 
extremities. 

When sitting down his legs and feet are usually quiet, 
but he has a most constant though not very marked move- 
ment of his head, trunk, and upper extremities ; his head is 
moved a little backwards or from side to side in an almost 
rhythmical manner ; his trunk is occasionally lifted or 
twisted as if about to shrug his shoulders ; he carries his 
left arm across his chest, the hand and fingers partially 
extended ; his right arm generally hangs by his side at full 
length ; both arms are kept comparatively quiet, but occa- 
sionally are shifted about uneasily ; his fingers and hands 
are constantly moving, going through a series of irregular 
or athetoid movements — perhaps one or two fingers are 
flexed while others are extended, or one or all fingers may 
be extended partially or fully ; sometimes the fingers are 
thrust apart or sometimes the thumb and fore-finger are 
brought together and then separated. If the hands are sup- 
ported on the knees, the movements lessen considerably ; 
occasionally he shifts the position of his hands or moves 
his fingers up and down. 

1 Journal of Nervous and Mental Disease, February, 1889. 



CHOREA AND TREMOR. I 35 

When he walks his choreiform movements are much in- 
creased. Athetoid movements of the fingers are especially 
marked. He walks with a sort of twisting or half rotating 
movement of the trunk and limbs, occasionally lifting one 
foot high in the air and bringing it down with a flourish, 
and every few steps pausing as if to poise himself. By a 
strong effort of the will the movements seem to be lessened. 
Voluntary effort such as writing, or conveying a glass of 
water to his lips, cause the movements to be less marked. 
Excitement of any kind greatly exaggerates his move- 
ments. He cannot protrude his tongue fully, and loss of 
power or control of the tongue seems to be of the same 
character as that shown in other parts of the body. 

Knee jerk and muscle jerk are considerably exagger- 
ated; slight ankle clonus is present on both sides. He has 
no loss of sensation. During sleep the movements cease 
entirely. His hand-writing is quite passable, but when he 
writes he seems to be putting forth extraordinary effort. 

The following is his signature: 





His speech is slow but quite intelligible; it seems to re- 
quire an extreme effort to co-ordinate the movements 
of articulation. He can read fairly well by holding the 
book against his chest to steady it. His general health is 
excellent; height 5 feet 11 inches; weight 145 pounds; 
lungs, heart and kidneys are normal. 

CASE III. — Hereditary chorea, with history of chorea in 
father and infant child. 

The notes of this case are meagre, but it is worth while 
to report it as it adds another authentic record to the statis- 
tics which demonstrate the peculiar hereditary character of 
this form of chorea. The patient, J. M., married, white, was 
41 years old at the time of coming under observation. 
Slight twitchings or choreiform movements began five years 
before, that is, when she was 36 years old. The disorder 
gradually increased. The movements were decidedly like 
those shown by the other cases of hereditary chorea re- 
ported in this communication. They affected the 
head, arms, legs, and speech, much more markedly on 
the right than on the left side. The patient- ate well, her 
sleep was broken, and her mental condition was one of 





I36 CHARLES K. MILLS. 

slight beginning dementia. Her father was affected with 
the same or a similar disease. He was a hard drinking 
man. She had a baby only four months old, almost cons- 
tantly affected with choreic movements of both hands. 
Signature: 



*> k^yi 



The following seem to be the peculiarities of movement 
and tremor in these cases of so-called hereditary chorea: 
The movements are usually first noticed in the upper ex- 
tremities, especially in the hands. The disorder spreads 
slowly and gradually, but very surely, to other parts, until 
the entire body is more or less affected, the upper extremi- 
ties commonly continuing to exhibit the symptoms in the 
most marked degree. Excitement increases, voluntary effort 
decreases the movements. When sitting or lying down the 
patient is much quieter than when standing or walking. 
Speech and writing areboth affected, and as the disease ad- 
vances require great effort on the part of the patient. Only 
in its very early stages would this disease be likely to be con- 
founded with any of the other forms of tremor or chorea. 
Very early it is conceivable that even disseminated sclerosis 
might be confounded with it; but early or late the the tremor 
of disseminated sclerosis is usually more confined to partic- 
ular parts; and in disseminated sclerosis voluntary effort 
markedly increases the tremor, while it has the opposite 
effect in hereditary chorea. Emotion aggravates both dis- 
orders. When the head is affected in disseminated sclerosis 
the movement is a more or less uniform oscillation, while in 
hereditary chorea the head is moved about in an irregular 
manner — forwards, backwards, or to one side, as if the 
exertion was partly under the control of the patient's will. 

Case IV. — Paramyoclonic chorea, with a history of 
other cases in the same family. 

C. E., aged 21, huckster, had three sisters who died of 
phthisis, at the ages of 4, 18 and 19 respectively. One 
brother died two years ago and was affected with the same 
disease as the patient, the age at which it developed and 
the causes not known. He has two brothers living, and 
he says that one of them has the same disease, only not so 
far advanced. In this brother the affection began at the 
age of 20 with no apparent cause, and has now existed for 



CHOREA AA'D TREMOR. 1 37 

over a year. His other brother is perfectly well. No his- 
tory of nervous disease on either paternal or maternal side 
could be elicited. The patient says that before the advent 
of his present disease he was always healthy, never used 
tobacco, or intoxicating drinks, and had no venereal history. 

Three years ago while huckstering his horse became 
frightened and ran away. When he found that the horse 
was beyond control he jumped from the wagon, hurt him- 
self, and became unconscious; on coming to his senses his 
whole body jerked as it does at present although not so 
markedly. He was carried home and put to bed and re- 
mained there for five weeks, at the end of which time he 
was able to walk with the aid of canes, but frequently fell 
down. At present he is unable to walk and must be carried 
from the bed to his chair, in which he must be tied or he 
would be thrown to the floor by the excessive, incoordi- 
nate, involuntary, universal movements. He is unable to 
feed himself because of jerking of the arms. His appetite 
and general health are excellent; he sleeps well and during 
sleep is frequently quiet. It is impossible to obtain knee 
jerk as the limb becomes rigid when an attempt is made to 
elicit it. He has slight left ankle clonus. He has control o 
bowels and bladder. He shows no impairment of sensation 
or of the special senses. 

The following is an attempt at a description of the char- 
acter of the choreiform movements: When lying quiet, not 
watched or spoken to, or excited in any way, he is com- 
paratively easy and may be perfectly quiet for several 
minutes or even much longer. Occasionally he will raise 
one or both hands slightly or it may be place them on his 
breast, or he may flex and extend the fingers in an irregu- 
lar manner. These movements are made slowly and at 
intervals, but usually from six to twelve in a minute. Ex- 
citement or emotion, or attempted voluntary effort, greatly 
increase the movements and they rapidly become general; 
they are violent, irregular, inco-ordinate, wild, and 
shock-like; they are more or less independent of each 
other, numbering from sixty to eighty per minute. During 
the excitation the body is thrown forward and backward, 
the head is moved from side to side and often thrown for- 
ward and backward quite strongly. The facial muscles are 
usually free except theorbicular muscles of the eyelids. His 
upper extremities move rapidly, and usuaMy irregularly and 
independently of each other. With the irregular movements 
he has at times certain automatically repeated acts. The 
most frequent of these seems to be a brushing of the head 
and face with the hands either open or closed, or a slapping 



I ^8 CHARLES K. MILLS. 

of one hand in the other, or on the knee. Frequently he 
throws his arms out at full length, then rapidly across his 
chest and face; or he may clasp his hands for a moment or 
execute some other irregular movement in the lower ex- 
tremities, not so marked as in the upper, but otherwise very 
similar. He flexes and extends his thighs, legs, and feet in 
the most irregular manner; occasionally his legs are extend- 
ed perfectly straight for a few seconds in what appears to be 
a tonic contraction, but it is due to a very rapid clonus. 
When he is lifted from his bed his body becomes 
rigid as a board; his arms are thrown wildly about, and his 
lower extremities become almost immobile by the extreme 
rapidity of the muscular contractions of the body and lower 
extremities. When he is placed on his chair the violent 
contractions jump him up and down for a min- 
ute or two. His speech is interfered with apparently 
through difficulty in co-ordinating the muscles of articula- 
tion, but when he commences to speak he talks quite 
rapidly. 

The mental condition of the patient seems to be unaf- 
fected by the disease, and his general physical condition is 
good. 

A careful consideration of this case shows points of great 
similarity between it and cases of hereditary chorea, al- 
though at first sight this resemblance might not attract at- 
tention. The movements are similar although far more 
violent and general. The history shows other cases in the 
same family. The case differs from hereditary chorea in 
having begun acutely, and at an earlier age than is common 
in the latter disease ; also in the much greater rapidity and 
violence of the inco-ordinate movements. 

Case V. — Tremor of Paralysis Agitans. 

A. K., age 54, a weaver, for sixteen years has been 
troubled more or less with chronic rheumatism, principally 
in the shoulder-joints. He is a very moderate drinker and 
smoker, and has no history of venereal troubles. 

About five years ago he first noticed a weakness in the 
right arm, and this has steadily progressed. Three years 
ago a tremor of the right hand and fingers first became 
manifest ; at first it was not constant and was more marked 
when under excitement. About one year ago the right 
foot "trembled" also, and within a month the left hand de- 
veloped a fine tremor which is not always present. This 
tremor is fine and rhythmical, and never ceases except 
during sleep. By an effort of the will it can be lessened 
but not stopped ; voluntary effort as in drinking from a 
glass, very much lessens it ; excitement increases it con- 





CHOREA AXD TREMOR. j 39 

siderably. Grasping the arm lessens it decidedly but does 
not cause it to cease. If the hand is rested on the knees 
the tremor continues but is less marked. There is slight 
stiffening of the right hand, and he writes slowly and with 
considerable effort, but comparatively well. 

The patient's shoulders are stooped, the head carried 
toward the chest and held fixed as if in a stock. The face 
is fixed, dull, and expressionless. He shows nothing pecul- 
iar in his gait. Sensation is not impaired. 

Signature : 

Several cases of paralysis agitans, more typical, or at 
least more advanced, than the one here reported are in the 
Nervous Wards of the hospital, but this case was selected 
for report and comparison because at a stage, so far as the 
tremor is concerned, when, if ever, it might be confused 
with some other affection. 

In the main, this case affords the diagnostic features 
usually given by the books ; the tremor is lessened 
by an effort of the will ; it is, however, increased by excite- 
ment. It is fine and rhythmical, and fixity of limb and 
feature are present. 

CASE VI. — Tremor of Disseminated Sclerosis. 

J. O., age 71, laborer, ten years ago had mild malarial 
and four years later break bone fever, both of these attacks 
persisting for about five months. Up to ten years ago he 
was a hard drinker. He is a heavy user of tobacco, both 
chewing and smoking. He has no history of venereal 
troubles. 

Two years ago he noticed a tremor of the right 
hand which first became apparent when he attempted to 
use the hand as in eating ; this gradually became so marked 
that when possible he rested his right hand and used the 
left one. In about two months he noticed that the left hand 
also trembled, and shortly after he felt the same tremor in 
his body and lower extremities, although not so marked. 

When the patient sits with his hands on his knees they 
are comparatively steady, but occasionally a fine tremor is 
seen. When his hands are extended without support, the 



I40 CHARLES K. MILLS. 

tremor is quite marked in both but more apparent in the 
right hand. When he attempts to control his movements by 
mental effort, the tremor is considerably exaggerated. If 
the hands or arms are grasped the tremor continues, and 
can be felt involving the entire linb. A marked increase 
occurs if a voluntary effort is made, as when he attempts to 
drink from a glass — the tremor then becomes wide, coarse, 
irregular and jerky, and in efforts to carry the glass to his 
mouth much water is spilled. There is a fine oscilation of 
the head, chiefly in a lateral direction, and occasionally a 
slight spasm or twitching of the zygmatic muscles of the 
right side of the face. The tremor involves the trunk 
slightly; he has also tremor of the tongue. 

Nothing particular is noticed about his gait except that it 
resembles that of paralysis agitans in thathis head is slightly 
bowed ; his face has rather a blank and listless expression, 
but this may be accounted for by his age and low intelli- 
gence ; he complains of weakness of both upper and lower 
extremities, especially of the right arm. The dynamometer 
shows a grasp of 26 for the right, and of 56 for the left hand. 
The least exertion fatigues him. This weakness first be- 
came manifest seven months ago and is steadily growing 
worse. There appears to be no impairment of sensation ; 
the pupils are equal, moderately dilated, and respond to 
light ; he has no nystagmus. Knee jerk is abolished and 
slight ankle clonus is present on both sides. He is fre- 
quently troubled with headache and vertigo, the latter being 
most marked in the morning. He speaks in a slow and 
tremulous manner. He has perfect control of the bladder 
and rectum. 

Case VII. — Tremor from abuse of tobacco and alcohol. 

J. R., aged 63, about a year ago began to be afflicted 
with tremor in both hands, which has become gradually 
worse during the last three months. He complains of feel- 
ing dizzy, and if he turns suddenly is in danger of falling. 
He has no headache, nor any pain in the body. He sleeps 
well but has no appetite. For the past thirty years he has 
been accustomed to drink several glasses of beer and 
smoke twelve pipes during a day. 

The tremor affects both hands about equally, it is coarse 
but not large, and keeps up continually without any vari- 
ation; it is sometimes increased by exertion. The arms as 
well as the hands are somewhat affected. Sometimes the 
tremor almost entirely disappears for one or two days; and 
in the latter part of the day is generally better than in the 
morning. 

Under enforced abstinence from alcoholic drinks and 



CHOREA AND TREMOR. 141 

tobacco, in about two months this man's tremor almost 
absolutely disappeared. The peculiarities of the tremor 
were its bilaterality, its complete discontinuance at inter- 
vals, its greater regularity than in disseminated sclerosis, 
its better response to treatment, and the absence in the 
patient of the other symptoms and conditions which are 
usually associated with paralysis agitans or disseminated 
sclerosis. 

Case VIII. — Diffuse undulatory tremor in a case of 
chronic spinal degeneration. 

C. J. H., age 53, had had some pain in the lower part 
of the back for years, after which he noticed trouble 
with his feet when walking down hill. He grew gradually 
worse, but had no history of true pain, only cramp or 
spasm in the calves. 

He cannot lift his toes in walking, stumbles and feels 
his feet under him. He has no trouble with his bladder or 
bowels. Twelve years ago he had some confusion of sight, 
but was relieved by glasses; he has no diplopia. The knee 
jerks are exaggerated. He has advanced paresis of both 
legs. The back muscles are not rigid. In the arms he 
has no palsy but a jerking or twitching of the muscles. 
For four months he has had cramps in the legs, and in the 
arms, but not so marked; also a dragging sensation on the 
left side of the lower part of the abdomen. He has, at 
times, a tingling sensation all over his legs, and sometimes 
in his arms. He has "sore" feelings in the thighs and legs. 

A marked and very peculiar feature in this case is an 
almost universal tremor of the muscles of the thighs, legs, 
arms, forearms and trunk. Testing him with electricity it 
was thought at first that the tremors were contractions pro- 
duced by the electrical application. Wave-like movements 
are present all the time. The surface of the body pre- 
sents the appearance of a gently undulating sheet of 
water. In the shoulders, arms, etc., almost every physio- 
logical movement of the muscular groups could be seen; 
the muscles could be picked out by these involuntary con- 
tractions. 

Case IX. — Diffuse undulatory tremor in a case of chronic 
spinal degeneration. 

G. B., 31 years old, white, married, two years before 
coming under observation noticed that his left leg began to 
fail, and six months later his right became similarly affected. 
In a few months the loss of power in the left lower extremity 
was very extensive; at the time of examination all the foot 
movements being abolished and those of the leg and thigh 
much. weakened. The right leg and the left upper extrem- 



142 CHARLES K. MILLS. 

ity paretic, but still retain considerable power. 
Knee jerk on each side are retained, muscle jerk increased; 
farado-contractility is retained, but somewhat di- 
minished in some of the atrophied muscles of the left leg. 
Sexual power is good; he has no affection of the bladder 
or bowels and no anaesthesia. 

The marked peculiarity of this as of the last case is 
the presence of a diffuse undulatory tremor, affecting both 
legs very generally. 

The tremor in these cases is similar to that observed 
in the tongue in some bulbar strophic cases, and doubtless 
its pathology is the same as in these, but it is very rare to 
observe this extreme and widespread undulatory muscular 
tremor affecting parts other than the tongue. 



EXOPHTHALMIC GOITRE. 

Before a branch of the British Medical Association, 
reported in the British Medical Journal, Jan. 4, 1890, 
Dr. Cheadle showed a case of exophthalmic goitre in a 
male subject, in whom recovery was maintained for more 
than twenty years. He considered the symptoms due to 
disorder of the medulla, of the upper cervical portion of 
the cord, the region of the cardio-inhibitory, accelerator, 
vasomotor, vomiting, and glycogenic centres, all of which 
were — some constantly, some occasionally — involved in the 
disease. In February, 1868, the patient suffered from char- 
acteristic vascular excitement, marked exophthalmia, en- 
larged thyroid, which pressed so severely on the trachea 
that the consequent dyspnoea compelled the patient to sleep 
sitting in a chair. Tincture of iodine was freely given, fol- 
lowed by improvement in the course of a week, and this 
had continued and steady. The tendency of the disease 
seemed to be toward slow recovery in from one to five 
years. Cases were on record from death from pressure on 
the trachea, from acute mania, from cerebral haemorrhage, 
from pulmonary congestion and anasarca, and from various 
intercurrent affections. One of the greatest dangers Dr. 
Cheadle considered to be persistent vomiting with diarrhoea. 
Absolute rest was essential in the acute stage, and opium 
with digitalis or belladonna. Galvanism was useful in the 
chronic state, but caused undue excitement in the acute 
form. L. F. B. 



CONGENITAL BILATERAL PLEUROPLEGIA AND 
FACIAL PARALYSIS. 1 

By A. SCHAPRINGER, M.D., 

NEW YORK. 

BECKY F., aet. eight years, was brought to the Eastern 
Dispensary of this city by her fourteen-year-old 
sister, on October 11, 1889, because of a cough that 
was accompanied by a muco-purulent expectorate, and 
was particularly troublesome at night. She was directed to 
the deparment for diseases of children, but by mistake went 
to my department, that for diseases of the eyes. Thus it 
happened that she came first under my observation. The 




peculiar appearance of her face impressed me at once and 
lead me to make a careful examination, the results of 
which are detailed below. 

Dr. H. Koplik, the attending physician to the depart- 
ment for the diseases of children at the dispensary, at my 
request, kindly turned the case over to me, and for this 
great favor I here again take occasion to thank him. 

1 Case presented at the meeting of the New York Neurological Society, 
December 3, 1889. 



1^4 A ' SCHAPRJNGER. 

The disease of the respiratpry tract for which the little 
patient sought medical aid stood in such distant relation- 
ship to the remarkable conditions which are described 
below, that I shall pass it over without any further refer- 
ence. 

The child is of a development corresponding to her age. 
The deposit of subcutaneous adipose tissue is rather scanty. 
She is possessed of the average intelligence. The circum- 
stances of the family have been such as not to have per- 
mitted them to send her to school, and as a consequence 
she has not yet learned to read. When walking, she 
stumbles and falls more frequently than other children of 
the same age. She declares positively that this is because 
of a weakness in her legs and not on account of a lack of 
appreciation of the irregularities and obstacles on the sur- 
face of the floor or sidewalk. 

She generally holds her head rigidly erect. The gla- 
bella is bulging, but otherwise there is nothing unusual 
about the skull. Her face is pale, expressionless, and 
presents a mask-like appearance. The naso-labial fold is 
absent on both sides. There is not the slightest indication 
of folds in the integument of the face either in laughing or 
in crying. On one occasion, when she was giving utter- 
ance to some peculiar inarticulate sounds, I inquired why 
she was crying, and was immediately enlightened as to the 
nature of the sounds by her elder sister, she informing me 
that the little one was laughing and not crying as I had 
supposed. The patient cannot close her lips, and in speak- 
ing, substitutes Unguals for labials, saying, for example, 
"tata" for "papa," and "nana" for "mamma." The right 
angle of her mouth is drawn downwards and outwards, and 
is the only place where any mimetical movements are 
noticeable. The little expression there is is to be perceived 
principally when she is talking. Whistling, blowing, etc., 
are absolutely impossible. 

She cannot wrinkle her forehead, either vertically or 
transversely. When her eyes are open the ordinary and 
normal amount of eyeball is uncovered. Usually both eyes 
are open to an equal extent, but quite often one lid or the 



COSGEMTAL BILA TERAL PLE UROPLE GIA . [45 

other hangs a little lower than its fellow. When required, 
the eyes can be fully and completely opened, showing that 
the levatores palpebrarum superiorum are not involved. 
Complete closure of the eyes is impossible, although upon 
a forcible effort the lids may be so nearly approximated 
that only a very inconsiderable interval is left between 
them. To this condition of the lids may be attributed the 
fact that the eyes have been protected from irritation. 
There is on either side, quite prominent, that abnormal 
crescentric fold of skin, covering the inner angle of the 
eye, and, at v Ammon's suggestion, called the epicanthus. 
The caruncle and plica semilunaris are only slightly devel- 
oped on both sides. They cannot be seen on a front view, 
and only become visible when looking from the side of the 
face towards the inner angle. 

Ordinarily the axes of the eyes are parallel. Frequently, 
however, the right eye is directed a little more upwards 
and slightly outwards. If an object be held in the median 
plane a few feet in front of the child's head and then she be 
asked to fix her eyes upon it, she does so without difficulty 
She is also able to follow the object with both eyes if it be 
lowered or elevated in the median line. If the object be 
approached to her face, keeping it in the sagittal plane, she 
follows it readily ; and she will keep her eyes fixed upon a 
finger held near the nose for a longer period without fatigue 
than is generally borne normally. These, however, are 
all the movements of which the eyeball is capable. They 
are rotation upwards, downwards, and convergence. When 
an object is moved to either side of the median line and 
the child is told to look at it, she invariably answers, " I 
see it ;" but she stares directly ahead, turning her eyes 
neither towards the right nor the left. This same condition 
obtains if the eyes be alternately covered by the hand. 
For example, if the right eye be covered and the object 
then moved out of the median line to the left, the uncov- 
ered eye does not follow the object, showing a paralysis of 
the external rectus of the left side. On the other hand, if 
the object be moved to the right, the eye does not follow it, 
showing a paralysis of the internal rectus of the same side. 



1^6 A. SCHAPRINGER. 

As we have seen, the two internal recti contract freely if 
required, in order to bring the eyes into convergence for 
near objects. If, however, one of these muscles be required 
to act in unison with the external rectus of the opposite 
eye, for a conjugate lateral version there will be found an 
utter inability to do so. The two external recti muscles 
are either completely paralyzed or entirely absent, as 
neither the right nor the left eye can be directed externally 
from the median line the least particle. On the other 
hand, the internal recti are only relatively paralyzed. They 
converge the eyes readily when required, but they are 
utterly unable to respond to an impulse which under nor- 
mal condition would induce a conjugate lateral version. 
When the child wishes to see an object situated to the side 
of the median plane, instead of rotating her eyes she turns 

her entire head. 

Under normal conditions the range of binocular fixation 

(not to be confounded with the field of vision) may be said 

to correspond to a geometrical solid with three dimensions. 

In the case under consideration, however, the range of 

binocular fixation is reduced to a sagittally placed plane, 

and as such it has but two dimensions, one of which is 

vertical and the other sagittal. 

With the ophthalmoscope the vessels in the fundus 
appear to be more tortuous than usual. Otherwise nothing 
worthy of mention is to be seen. 

The left eye is practically emmetropic, having only a 
slight degree of astigmatism. The right eye is myopic to 
the extent of about 3 D. This is the eye which, as was 
stated before, is directed upwards and slightly outwards 
when looking at a distance. In order to avoid losing the 
good will of the child I refrained from carrying the rather 
wearying tests for the determination of the acuity of vision 
out to completeness. As far as could be determined, V. 
was nearly, if not quite, normal in both eyes. 

The ophthalmoscopical observations were conducted 
without the aid of mydiatics, and the little patient's efforts 
of accommodation proved a great obstacle. They showed, 
however, that the functions of the ciliary muscles were 



CONGENITAL BILATERAL PLEUROPLEGIA. 1 47 

unaffected, which could also be demonstrated in other 
ways. 

With reference to certain analogous cases reported by- 
other observers, it would be well to state explicitly that 
there is no strabismus convergens, and that there is not 
the least trace or scar of a former tenotomy or myotomy, 
and that, furthermore, in looking downwards there is no 
abnormal convergence of the axes of the eyes. 

The size and mobility of the pupils are perfectly normal. 

When the tongue is protruded it is deflected a little to 
the left of the median line. The left half of the tongue is 
a trifle smaller than the right half. 

Movements may be made in all directions, but not with 
the requisite completeness and force. When eating, the 
child is obliged to use her finger to dislodge food from her 
cheeks. She says that she is unable to masticate hard sub- 
stances, such as bread-crusts. If a hard body is placed between 
her teeth, she is able to hold it there quite firmly. She can 
move the lower jaw laterally towards the right side, but not 
towards the left, indicating a paralysis of the right external 
pterygoid muscle. She has uvula bifida. The child herself 
called my attention to a remarkable anomaly in her mouth, 
which I should certainly not have thought of looking for 
otherwise. The cord-like structure, which may be felt by 
passing the finger along the buccal mucous membrane 
between the alveolar process of the upper jaw and the 
cheek in the neighborhood of the canine fossa, and spoken 
of by the dentists as the lateral frenulum or canine liga- 
ment, is enormously developed in this case on the right 
side, while on the left side the state of its development is 
normal. What significance can be attached to this condi- 
tion I am not prepared to say, my opportunities for making 
anatomical investigations in regard to it having been too 
meagre. Hearing, taste and smell are normal, as is also 
the sensibility of the skin. 

I wish to express my great obligations to Dr. Geo. W. 
Jacoby for helping me during the examination of the ner- 
vous symptoms of this case. 

The distal phalanx of the left index finger is bent out of 



I48 A. SCHAPRINGEK. 

the long axis of the finger at an angle of about 150 in the 
direction of the middle finger. The affected interphalangeal 
joint possesses the normal mobility, and there is not the 
least trace of a previous inflammation. All the circum- 
stances point towards the defect being a congenital one. 

The anterior aspect of the thorax shows an extra- 
ordinary deformity. The sternum is deeply sunken in, 
and presents a long vertical groove situated beetween two 
prominences formed by the bulging of the anterior portions 
of the sites on either side. Dr. Abraham Jacobi, who 
examined this deformity at my request, pronounced it a 
not very well-marked example of that form of imperfect 
development known in the literature of the subject as 
"funnel chest." 

No other deformities, such as webbed fingers and toes 
are discoverable. 

The parents of our patient are natives of Russia, where 
the patient was also born. They are divorced and live in 
distant parts, while the child and her elder sister are being 
brought up by an uncle. The parents are not consan- 
guineous. The sister of whom mention was made before is 
physically well developed and looks healthy. Another 
child, however, of the same parents died at the age of a 
few months. The child who is the subject of this paper is 
said by her relatives to have been free from any anomalies 
at birth, except the before-mentioned angular index finger. 
The relatives also state that the distortion of the mouth 
was developed subsequent to an attack of convulsions 
which occurred in her early infancy. According to another 
version, the blame attaches to injury received by striking 
her head in a fall. It is perfetly manifest that no weight 
can be given to those accounts, and that we must consider 
the anomalies as congenital. 

The most interesting features of the case are unques- 
tionably the lesions of the nervous system. They include 
the motor branch of the trigeminus, the hypoglossus and 
the facial, but particularly those nerve tracts of both eye- 
balls that control the conjugate lateral version. I should 
like to confine myself to the consideration of this last 
anomaly entirely. 



CONGENITAL BILATERAL PLEUROPLEGIA. 149 

Previous to this there has been no simple and concise 
term to designate the condition of paralysis of the con- 
jugate lateral version of both eyes to the right or to the left, 
or, as in this case, to the right and the left with preser- 
vation of convergence. I therefore suggest the 
name " neuroplegia, " deriving it from the Greek word 
pleuron, the original meaning of which is "the side." The 
word is constructed similarly to "Pleurothotonus," by which 
we designate a convulsion that draws the body to one side 
and is seen in tetanus. In the succeeding portions of this 
article the reasons for the introduction of this kind of term 
will be shown to be timely as well as conducive to a clearer 
conception of the subject. 

neuroplegia (or to be more exact, ophthalmopleuro- 
plegia,) is generally seen in diseases of the pons, such as 
neoplasms, haemorrhages, the softening due to arterial 
thrombosis, etc., and is usually unilateral. In attempting 
to explain this phenomenon we have to reason about as 
follows : 

Given a case where there is left-sided pleuroplegia, with 
the power of convergence retained, the following parts 
must be undisturbed in regard to their anatomical structure 
and their functions : 1st. The two internal recti muscles. 
2d. That branch of the motor-oculi that supplies these 
muscles. 3d. The two nuclei for the internal recti. 4th. The 
two intracerebral paths which connect the nuclei of the 
internal recti with the centre of voluntary convergence. 
This is supposed to be a single centre situated in the cor- 
tex. 5th and last. This convergence centre itself. In our 
supposed case the lateral conjugate movements toward the 
left side are completely arrested. This movement is ac- 
complished by the external rectus of the left eye and the 
internal rectus of the right eye. 

We shall now study the innervation of these individual 
muscles separately. 

Since the left external rectus is completely paralyzed, 
the following series of neuro-muscular structures may be 
regarded as having been rendered inactive: 1st, the left 
rectus externus ; 2d, its supplying abducent nerve ; 3d, the 



150 A. SCHAPRINGER. 

abducent nucleus in the pons ; 4th, the nerve tract which 
connects this nucleus with that portion of the cortex of the 
right side of the brain in which the centre that presides 
over the voluntary left lateral version of both eyes is situ- 
ated ; 5th, this centre itself. 

The right internal rectus muscle is only relatively paral- 
yzed, that is only in regard to conjugate lateral version. 
There is no impairment of its power of convergence. If we 
now follow the chain that connects the right internal rectus 
with the voluntary centre of conjugate left lateral motion, 
we have : 1st, the muscle under consideration ; 2d, its 
innervating branch from the right motor-oculi ; 3d, the 
right internal nucleus. At the internal nucleus the impulses 
of convergence and of conjugate lateral version separate. 
For the internal nucleus has two lines of communicution 
with the cerebrum. The one connecting it with the centre 
of voluntary convergence has been discussed, the other 
which will now engage our attention is that which connects 
it with the centre of voluntary conjugate lateral version. 
This centre is located in the cortex of the right hemisphere, 
that is on the same side as that internal nucleus to which 
we had come in the course of our progress from without 
inwards. The connecting path between the right internal 
nucleus and the centre of voluntary conjugate lateral ver- 
sion in the cortex of the right hemisphere is not, however, 
a perfectly straight one confining itself within the bound- 
aries of the right cerebral hemisphere, but takes part of its 
course through the substance of the left hemisphere, making 
a sort of loop and passing quite close to the nucleus of the 
left abducens. This is the same abducens nucleus that we 
met before in the course of our analysis. So near to this 
nucleus do the connecting fibres pass that a lesion of the 
nucleus almost invariably involves them. The course of 
the fibres carrying the impulses of conjugate left lateral 
motion are undivided from their origin in the cortex of 
right hemisphere until they reach the neighborhood of the 
left abducens nucleus. Here, however, they iplit into two 
divisions, one of which joins the left abducen nerve, while 
the other passes over to the opposite side into the right 



CONGENITAL BILATERAL PLEUROPLEGIA. 151 

internal nucleus and by means of this communicates with 
its respective branch of the oculo-motor nerve. If the 
central communicating fibres are injured in any part of 
their course, there will result as a consequence an absolute 
paralysis of the left external rectus and a relative paralysis 
of the right internal rectus. In other words, a left-sided 
pleuroplegia. This would, of course, also follow from lesions 
involving either of the two terminals, that situated in the 
right cortex, and the left abducens nucleus. 

What has been said in reference to left-sided pleuro- 
plegia holds good mutatis mutandis of that of the right 
side. 

That the term "paralysis of the abducens" for this con- 
dition is insufficient and consequently conveys an erroneous 
impression, is manifest, but still it is used in the literature 
of the subject. Perhaps che term "nuclear abducens paral- 
ysis" would be morre corect. Even this, however, will not 
answer as a designation for the clinical symptom as such, 
because it makes a topical diagnosis, which, while it may 
apply to a large number of the cases, will not apply to all 
of them. 

The terms "deviation conjuguee" and "paralysie con- 
juguee" remind us that we are indebted to a group of 
French investigators for the original clinical observations 
concerning this symptom. I shall only mention the dis- 
coveries of Achille Foville and Fereol. Foville first pub- 
lished, in 1858, the observation that in unilateral disease of 
the pons there is a paralysis of associated lateral motion of 
the eyeball toward the side on which the lesion of the pons 
was situated. 

In 1872, Fereol called attention to the seeming para- 
doxical circumstance that the internal rectus responded 
freely to the impulses of convergence while it was power- 
less to carry on the motions of conjugate lateral version. 
The terms "conjugate deviation" and 'conjugate paralysis" 
are both applicable to disturbances of motion in every pos- 
sible direction, and it is always necessary to denote the 
direction, whether upwards or downwards or to the left, 
etc., by the appropriate words. Of all the conjugate paral- 



Itj2 A. SCHAPRINGER. 

yses that which we have called " pleuroplegia" is of the 
most frequent occurrence, and, because of the twofold role 
played by the internal rectus muscle, the most interesting. 

In not every case where pleuroplegia or pleuroparesis 
exists is the condition to be discovered by any marked 
deviation of the eyes. This is well illustrated by the fol- 
lowing case which came under my own observation : 

A four-year-old girl fell down stairs, and was brought 
to the Eastern Dispensary. Dr. W. W. Van Arsdale, to 
whom she was first presented, asked me to examine her 
left ear from which there had been some bleeding. At the 
time we saw her the child was perfectly conscious and in 
good spirits. There was no eye symptom complained of, 
and nothing remarkable was to be seen. It chanced that I 
had had a case, a short time previously, of paralysis of 
certain muscles of the eye, and that led me to investigate 
the mobility of the eyeball in this case. The child when 
requested to follow a finger with her eyes, could only do so 
in the left half of the field of fixation. To the right she 
could only follow a trifle beyond the middle line, and there 
the eyes remained in a sort of nystagmus-like motion. 
There was a difference in the two eyes, inasmuch as the left 
eye went a little further beyond the middle line than the 
right. I know nothing of the future of the case, as the 
parents never brought her again. 

For the sake of completeness it may be mentioned that 
the opposite condition to pleuroplegia, namely, a paralysis 
of convergence, with retained conjugate lateral motion, has 
been observed and is being regarded with increased atten- 
tion in the newer literature. If a short expressive term for 
this symptom is desired, that of "mesoplegia" is suggested. 

In the case described here the symptoms are evidently 
due to a lack of development involving the nuclei of the 
abducens, facial, hypoglossal and trigeminus nerves. 

It is because of the close neighborhood of these nuclei 
that this seems the most reasonable explanation of the 
symptoms. The inconstant strabismus sursum vergens, 
alternately now in one eye and then in the other, denotes 
that along with the formative defect there is an active 



CONGENITAL BILATERAL PLEUROPLEGIA. \ 53 

unstable cause at work, in regard to whose nature I may be 
excused from theorizing. 

Only four parallel cases have as yet been recorded in 
literature. They are the cases of "congenital bilateral 
abducens facial paralysis" of Alfred Graefe (Halle), 2 G. C. 
Harlan (Philadelphia), 3 Julian J. Chisolm (Baltimore), 4 and 
P. J. Mobins (Leipzig). 5 The present one is the fifth case. 

Of the five cases under consideration, although agreeing 
in the principal points, not a single one is exactly similar to 
any of the others in all of the particulars. In Graefe's case 
the -facial paralysis was complete only on the left side ; on 
the right side there was paresis. In the cases of Harlan, 
Chisolm and Mobius the paralysis was complete only in 
the upper portions of the face. In the lower portion there 
was some mobility about the angles of the mouth. In our 
case only the right corner of the mouth is mobile. 

In regard to the impaired mobility of the eyes, there 
was in Harlan's and Chisolm's cases congenital converging 
strabismus. In Chisolm's case the patient had undergone 
a myotomy of the internal recti in early childhood. When 
Chisolm saw this patient she was thirty-five years of age, 
and her eyes were parallel. As in the other three cases, 
there was in those of Harlan and Chisolm a complete paral- 
ysis of the abducens on both sides. These observers have 
not stated clearly whether the shortened- internal recti 
muscles responded to an impulse of accommodation. Har- 
lan merely says that the function of all the orbital muscles 
but the abducent seemed normal. Chisolm states that in 
his case the lateral motion in both directions was absolutely 
impossible, because the abducens of either side was paral- 
yzed from birth on the one hand, while on the other hand 
the power of the internal muscles had been completely 
arrested by the operation for the strabismus. One misses 



2 Graefe-Saemisch, Handbuch der Augenheilkunde, Bd. vi., p. 60; also 
Siebenter Periodischer In tern at. Ophthalmologen-Congrcss, 1888, p. 30. 

3 Transactions of the American Ophthalm. Society, 1881, p. 216. 

4 Arch, of Ophthalm., edited oy Knapp and Schweigger, vol. xi., p. 323 
(1887). 

3 Miinchener Medicinische Wochenschrifr, 1888, No. 6 (February 7). 



154 A SCHAPRINGER. 

in the last case a definite statement as to the ability to 
converge, especially as Chisolm found it necessary to order 
convex glasses for hyperopia, in order to enable her to see 
clearly while sewing. In the three other cases, namely, 
those observed by Graefe, Mobius and myself, no converg- 
ing strabismus was present. 

There is a remarkable similarity between Graefe's case 
and the one described in the beginning of this article in 
regard to the differences of refraction existing in the two 
eyes. In both cases the right eye is myopic while the left 
one is emmetropic. Furthermore, in both cases there is 
the slight vertical deviation of one eye. In Graefe's case, 
however, the left eye was directed a trifle lower permanently, 
while in our case the deviation was not constantly mani- 
fested, sometimes the right eye and at other times the left 
squinting upwards. In looking at an object held close to 
the face, this upward deviation, when existing, would 
always disappear in our case. 

Mobius observed a difference in this respect only when 
the glance was directed downwards. The mobility of the 
eyeballs was limited in the downward movement and con- 
vergence always took place. It may be well to state here 
that in our case there was no abnormal limitation of 
downward movements, and that in fixing the gaze upon 
near objects in a downward direction there never is an 
excessive or abnormal convergence. 

So far there has not been a report of an autopsy on a 
case where this complication of symptoms existed. 

The epicanthus, the bulging glabella, the uvula bifida, 
the crooked index finger and the undeveloped funnel-chest 
are unique accompaniments, as are also the anomalies exist- 
ing in the regions supplied by the trifacial and hypoglossal 
nerves. Mobins observed in his case a web between two 
fingers of the right hand. 

The first observation of paralysis of the lateral motion 
of both eyes was made by Stellwag v. Carion. 6 In his case, 

6 Ueber gewis=e Innervations?torungen bei der Basedow's chen Krankheit. 
Wiener Med. Jahrb , Bd. xvii., p. 25 (1869). First Case. 



CONGENITAL BILATERAL PLEUROPLEGIA. I 55 

however, the affection was not congenital. It occurred 
when the patient was twenty years of age, in the course of 
a strumous exophthalmia. The description of the earlier 
stage of this case corresponds essentially to the conditions 
found by Graefe, Mobius and myself. The axes of both 
eyes were parallel to each other and to the median plane, 
while movements to the right or left were impossible to the 
slightest extent. The power of convergence was fully 
retained. The conditions present in a subsequent stage, 
however, resembled rather those found by Chisolm and 
Harlan. Both eyes, especially the left one, were directed 
inwards. If the object the patient was looking at was 
moved out of the median plane to the right or the left, the 
corresponding eye only followed it until it stood parallel to 
the median plane, beyond which it never went, the opposite 
eye remaining in a strongly adducted position. Later 
again, the right eye returned to its normal position, while 
the left eye was directed a trifle to the inner side. During 
the course of the illness other severe complications arose, 
such as asthmatic attacks and mental disturbances. The 
limitations of the mobility of the eyes decreased constantly 
and the condition of the visual organs had almost returned 
to the normal state when the patient withdrew from ob- 
servation. 



A NEW MECHANICAL TREATMENT FOR TABES. 

The " Times and Register," Nov. 3, 1889, reports from 
the " B. klin. Wochenschrift," according to Juergensen, 
favorable results obtained in tabes dorsalis from the appli- 
cation of Hessing's corsets, made from finely woven cloth 
and thin steel ribs. The freeing of the spine produced by 
wearing the corset soon results in relief from cystic and 
intestinal trouble ; then the lancinating pains cease, and the 
patient walks better. The patellar reflexes are not restored. 
General improvement is most marked. The corset must be 
worn for years, under the supervision of the maker. No 
explanation is given by Juergensen, unless the circulation 
and nutrition of the cord are improved by the extension of 
the spine. Erb has seen favorable results in two cases from 
this treatment. L. F. B. 



A CASE OF MULTIPLE CEREBRAL SOFTENING, 
WIDESPREAD ENDARTERITIS, DISSECTING 
ANEURISM OF BRANCH OF LEFT MID- 
DLE CEREBRAL ARTERY. 1 

By CHRISTIAN A. HERTER, M. D., 

Physician to the Class of Nervous Diseases, Presbyterian Hospital Dispensary. 

FOR the opportunity of studying the case here reported 
I am indebted to Dr. Andrew H. Smith, under whose 
charge the patient lay in the Presbyterian Hospital. 

The patient, M. L. D., was thirty-two years of age, mar- 
ried, and a native of the United States. Her father died at 
an advanced age in a state of apoplexy. With this excep- 
tion the family history is negative. The early history of 
the patient is without special interest. She has had two 
healthy children. One was born during the twenty-third 
year of her age, the other during her twenty-fourth year. 
Both were born at full term. Soon after the birth of the 
second child, the patient again became pregnant, but the 
pregnancy was arrested in the third month by the use of 
instruments, without the knowledge, it is said, of the hus- 
band. The patient made a good recovery from the abortion. 
No history of syphilis can be elicited from any source. 
The husband had no hesitation in stating that he had sev- 
eral times had gonorrhoea, but was certain that he had 
never had a chancre or secondary manifestations of syphilis. 
A careful examination of the patient revealed no evidences 
of syphilis. The possibility of syphilitic infection cannot, 
however, be positively excluded. 

The patient has always used alcohol, in the form of beer 
and light wines in moderation, never in excess. 

Up to the beginning of her fatal illness the patient was 
in ordinarily good health. She ate and slept well, and had 
no ailments other than constipation and an occasional 
headache. 

On the morning of March 2, 1888, soon after waking, she 

1 Read before the New York Neurological Society, Pebruary 4, 1890. 



MULTIPLE CEREBRAL SOFTENING. I 57 

complained of numbness of the left foot and of weakness of 
the left leg, which condition is said to have continued 
stationary during that day. On the following morning the 
paralysis was more obtrusive, and was observed to have 
extended to the left arm, which was markedly paretic. 
On trying to stand erect, after rising from bed, the patient 
fell to the floor. The leg paralysis is said to have been 
complete. No anaesthesia or analgesia of the arm was 
observed. 

In the course of two or three weeks the patient gained 
sufficient power in the left leg to enable her to walk with 
the aid of a cane. Recovery of power in the arm was more 
rapid and complete. The patient continued to drag her leg 
in walking. 

During the interval between the attack just described 
and the second seizure, the patient's general condition was 
good. She ate and slept well and was free from headache. 
It was observed, however, that her disposition was some- 
what changed. She had grown irritable and capricious. 

On November 5th, of the same year, seven months after 
the onset of the left hemiplegia, the patient experienced a 
new attack. Soon after she arose in the morning, the hus- 
band observed that she had some hesitation in speech ; she 
spoke slowly and apparently with difficulty, and committed 
errors in the use and form of words. She was also unusually 
silent during the morning, but did not complain either of 
pain or weakness. 

At three o'clock of the same day the patient became 
giddy and fell to the floor. She soon complained of loss of 
power in the right leg and arm, the face being unaffected. 
The mental state of the patient was dull and listless. No 
loss of consciousness, strictly speaking, occurred at the 
time of the attack. She was apathetic, but could be roused 
without difficulty at any time, and appeared to recognize 
those about her. At no time did she complain of pain or 
discomfort. She replied in an incoherent manner and with 
increased hesitation to questions put her. It is said that 
she never took the initiative in speaking, and never volun- 
teered any information without being first interrogated. 

On November 15th, ten days after the second attack, the 
patient was admitted to the Presbyterian Hospital, in a state 
of mental hebetude. The following notes were made soon 
after admission : 

Examination shows the patient to be poorly nourished 
and anaemic. Temperature, pulse, respiration, and urine 
normal ; urates very abundant in urine. Heart negative, 



I 5 8 CHRISTIAN A. HER TER. 

sounds feeble ; lungs normal, respiratory murmur feeble ; 
spleen normal ; stomach somewhat dilated ; area of liver- 
dullness encroached upon by area of tympanitic resonance 
from stomach and intestines ; below free border of the ribs, 
on the right side, a movable boggy mass is felt, presumably 
fecal in nature ; it is difficult to accurately determine the 
condition of sensibility; sensibility to pain and touch are 
normal ; the temperature sense seems normal ; the condi- 
tion of the muscular sense cannot be determined; the super- 
ficial and deep reflexes are present on the left side ; on the 
right side the knee-jerk is feeble and is obtained with diffi- 
culty ; the plantar reflex is absent on this side ; the abdom- 
inal and epigastric reflexes are present. The pupils are 
equal in size, and moderately dilated ; they react during 
accommodation ; to light they react slightly and sluggishly. 
Sight, taste, hearing, and smell seem normal. The hemi- 
plegia is difficult to make out, owing to the mental state. 
The patient lies upon her back, with arms and legs ex- 
tended, without changing her position. She sleeps a large 
part of the day, but is readily roused from her stupor for a 
few seconds. She makes no complaints and never volun- 
teers to speak, but occasionally replies incoherently to a 
question. While awake the eyes are commonly fixed on 
some distant object. The patient is entirely indifferent to 
what transpires about her. Her appreciation of time and 
place is highly defective. Urine and faeces are passed un- 
consciously. There is no sphincteric weakness. 

There was no material change in the condition of 
the patient until November 30th, two weeks after admis- 
sion, when it was observed that she had a temperature 
of ioo°. 

During the remaining period of the patient's life, a period 
of two weeks, the temperature ranged irregularly between 
101 and 104 , the average temperature growing gradually 
higher from day to day. There were no rigors. No physi- 
cal signs of thoracic disease were at any time detected, 
though repeated examinations were made. There was no 
cough. 

One week before death the pupils were observed to be 
somewhat more dilated than before, the left being the 
larger. Four days before death there appeared conjugate 
deviation of the eyes to the left. This condition continued, 
without undergoing modification, until death. Ophthalmo- 
scopic examinations were made every second or third day 
during the last three weeks of the patient's life, but failed to 
show any changes in the fundus oculi. 



MULTIPLE CEREBRAL SOFTEXIXG. 



'59 



About the time of the development of conjugate devia- 
tion, the left arm was observed to be in a state of catalepsy. 
The muscles of the arm imposed a wax-like resistance to 
passive movement ; but this resistance was readily over- 
come, the arm remaining for some time in any position 
impressed on it. This condition was very marked in the 
muscles moving the elbow-joint, and continued, until the 
death of the patient, as a constant phenomenon. In the 
shoulder-muscles it was less pronounced and of shorter 
duration. 

On the morning of December 14th the patient died in a 
comatose condition. 

AUTOPSY. — Double hypostatic pneumonia. No cardiac 
disease. Xo renal disease. Meninges normal. Left hemi- 
sphere distinctly larger in every dimension than the right. 
No evidence of disease on external surface of cerebral 
hemispheres. Examination of the larger arteries at the 




Fig. 1. 

base of the brain shows no evidence of vascular disease. 
A number of coronal sections were made through the 
hemispheres at short intervals. They show the existence 
of several foci of softening. One of these occupies a con- 
siderable part of the left frontal lobe, as is seen in Fig. 1. 
(a) which roughly indicates its limits in one plane. This 
patch of white softenings is also seen in Fig. 2 (a), where 
its extent is less than in Fig. 1. It extends far forward 
into the frontal lobe, probably to within 1 cm. of the cortex. 
Posteriorly it extends about 1 cm. caudad of the plane 
represented in Fig. 2, but is here of small lateral extent. 



i6o 



CHRISTIAN A. HERTER. 



Anteriorly the left half of the callosum is destroyed by the 
softening as far as the median line. As the lesion is fol- 
lowed back, the callosum is involved at a distance from 
the median line. A pigmented connective-tissue cicatrix 
is present in the right hemisphere in the situation indicated 
in Fig. 2, i.e., occupying the lateral part of the caudate 
nucleus and the mesial part of the internal capsule. This 
focus is of considerable antero-pqsterior extent (about \% 
cm.), but occupies the lateral part of the caudate nucleus 
and the mesial part of the internal capsule in all the sec- 
tions in which it appears. Immediately frontad and caudad 
of the plane shown in Fig. 2, the lesion becomes somewhat 




Fig. 2. 
smaller. This focus undoubtedly indicates the position of 
an old area of softening. Another focus of softening is 
seen in the right temporal lobe just beneath and involving 
the cortex. Still another patch existed in the left occipital 
lobe, but its exact position was not noted. A microscopical 
examination of material from the large focus of softening 
showed it to consist of broken down brain-tissue, remains 
of nerve-fibres, droplets of myeline, a moderate number of 
red blood-cells, very few white blood-cells, compound 
granular corpuscles, and debris. 

A number of the smaller arteries were examined care- 
fully, both macroscopically and microscopically, among 
them both middle cerebral arteries and several of their 
branches, and both anterior cerebral arteries. Without 



MULTIPLE CEREBRAL SOFTENING. 



161 



exception all the vessels examined were the seat of endar- 
teritis. In some cases the increase of connective-tissue in 
the intima was slight in amount, in others the formation of 
new connective-tissue was so extensive as to seriously 
encroach upon the lumina of the vessels. In many sections 
there was a moderate degree of periarteritis. In some of 
the branches of the left middle cerebral artery the changes 
in the walls of the vessels were very advanced, more 
advanced than in any other arteries examined. Degenera- 
tive changes (fatty degeneration, calcification) were not 
observed in any vessel. 




Fig. 3. 

A remarkable condition was discovered in a large 
branch of the left middle cerebral artery. The walls of 
this vessel, in addition to being the seat of endarteritis, 
were separated by a haemorrhage of considerable size, con- 
stituting a dissecting aneurism. The longitudinal extent 
of the aneurism was nearly one inch, but no accurate 
measurement was made. Fig. 3 represents the appearance 
of a transverse section of the vessel. The effusion of blood 
occurred between the elastic layer and the media, the 
former being crowded over to one side of the vessel. The 
effused blood which thus separated the walls of the artery 
occupies a large area. On either side of the space occupied 
by the haemorrhage large numbers of red blood-cells are 
seen heaped together (in the drawing the cells are repre- 
sented disproportionately large). In the remaining space 



I 62 CHRISTIAN A. HERTER. 

the effused blood shows signs of organization. The area is 
transversed by numerous streaks of fibrin forming a fine 
meshed network. A high power shows these meshes to be 
filled with large numbers of red blood-cells, which have 
lost their color and lie massed together. In the loops 
formed by the compression of the elastic layer, lie impris- 
oned many red cells. The intima is the seat of an endar- 
teritis of considerable intensity. The lumen of the vessel 
is occluded by a small thrombus, apparently of the same 
age as the large clot. The vessel is the seat of a moderate 
degree of periarteritis. No condition similar to that just 
described was found in any other vessel. Neither was the 
lumen of any other vessel examined completely obliterated. 
Unfortunately, the exact position of the vessel which was the 
seat of the dissecting aneurism was not carefully observed, 
the relations having been lost before it was discovered that 
the artery was of especial interest. 

Observations. — No accurate diagnosis of the nature (soft- 
ening) of the cerebral lesions above described was made 
during the life of the patient, as nothing whatever was 
known of her history before admission to the hospital until 
the time of her death, when the facts incorporated in the 
clinical history were brought to light. As the patient could 
give no account of herself, the diagnosis rested entirely upon 
the objective features of the case. For a considerable period 
the mental defect and right hemiplegia were the only evi- 
dence of an intracranial process. The lesion causing the 
hemiplegia was thought to be located in the internal cap- 
sule, or in the motor path between the capsule and the cor- 
tex, and the grave mental failure was referred to a destruc- 
tive process involving one or both frontal lobes. As to the 
pathological character of the lesion, no opinion was haz- 
arded. Haemorrhage was considered improbable, because 
of the age of the patient and the absence of the causal 
indications of haemorrhage — atheroma of accessible arteries 
and Bright's disease. The absence of arterial and renal dis- 
ease made softening from atheromatous thrombosis improb- 
able, and there was nothing to suggest embolic softening. 
Other forms of softening were not seriously considered. 



MULTIPLE CEREBRAL SOFTEXING. 163 

Abscess was thought of, but could not be regarded as prob- 
able. The absence both of irritative phenomena and optic 
neuritis made it unlikely that the symptoms could be re- 
ferred to a new growth. Viewed in the light afforded by a 
study of the lesions found in this case, there are two clinical 
features that require comment — the high grade of mental 
defect observed, and the existence of catalepsy. The men- 
tal defect can undoubtedly be referred in part to the destruc- 
tion of a considerable portion of the left frontal lobe, as the 
lesions in other parts of the cerebrum are of small extent. 
But the mental failure seems entirely out of proportion to 
the extent of destruction in the frontal lobe. The corpus 
callosum was softened at its anterior extremity, and it is 
not improbable that the destruction of this important com- 
misural tract is responsible for a degree of mental loss that 
cannot be accounted for by the mere extent of the lesion in 
the frontal lobe. 

The existence of localized catalepsy is of interest in 
connection with the lesion observed in the right internal 
capsule and caudate nucleus. This focus, which is older 
than the larger lesion on the left side, is unquestionably 
related to the first hemiplegic seizure noted in the clinical 
history. Perhaps it is also related to the catalepsy, but no 
positive expression of opinion can be ventured on this 
point. The fact that the catalepsy was localized and not 
general in its distribution makes it reasonable to sup- 
pose that it is dependent on the focal lesion described 
rather than on the mental state, but only future observa- 
tions can determine whether this symptom ever possesses 
localizing value. 

But by far the greatest interest of this case lies in the 
peculiar form of arterial disease that has been described. A 
dissecting aneurism led to the perfect occlusion of an 
artery of considerable size. This artery was an important 
branch of the left middle cerebral. Unfortunately, its 
exact location was not noted, and no positive statement 
can be made with regard to the area supplied by it. Yet 
the fact that it was completely occluded and that none of 
the other vessels examined were so occluded, makes it 



164 CHRISTIAN A. HEN TEA'. 

highly probable that the aneurism was operative in the 
production of the softening, though possibly not of the 
entire area. The time at which the second attack of hemi- 
plegia occurred corresponds closely with the appearance of 
the clot, and there can be no reasonable doubt that there is 
a direct causal relation between the intra-arterial haemor- 
rhage and the softening in the motor path to which the 
paralysis is due. 

In regard to the origin of the dissecting aneurism there 
is little to be said. Possibly it is related to the pre-existing 
endarteritis, but it is certainly an exceedingly rare conse- 
quence or association of such endarteritis. In the literature 
at my disposal I have been unable to find a description of 
any condition resembling even remotely that which I have 
described. 

The nature of the endarteritis is also obscure. It is true 
that it involves chiefly the smaller vessels, and that no 
degenerative changes can be detected in the vascular walls, 
and such endarteritis is usually looked upon as rather 
characteristic of a syphilitic origin. Possibly the endarte- 
ritis is of syphilitic origin, notwithstanding the improbability 
of syphilitic infection in this case. I believe that many cases 
of endarteritis are set down as syphilitic where such origin 
is highly improbable, and that future research will bring to 
light causes of endarteritis at present not appreciated. In 
my experience it is a prevalent belief that cerebral soften- 
ing is not infrequently a primary affection, occurring with- 
out the existence of vascular disease. Probably one reason 
for this belief is that it is not uncommon to examine the 
cerebral arteries in cases of softening in an imperfect man- 
ner, arterial disease being excluded because the important 
vessels at the base appear normal. If the presence of 
vascular disease were excluded only after a careful exam- 
ination of the vessels, large and small, I believe that 
primary cerebral softening would no longer be recognized. 



A CONTRIBUTION TO THE STUDY OF EPILEPSY. 

By FRANK H. INGRAM, M. D. 

Pathologist the N. Y. City Asylums for the Insane; Visiting Physician to the Hospital for 
Nervous Diseases. 

IN observing a large number of cases of epilepsy for a 
long period, one is necessarily impressed by the various 
phases which the disease manifests in one person, and by 
the difference in the character and in the sequence of the 
convulsive phenomena in different persons. Viewed from 
a purely clinical stand-point, it would seem a comparatively 
easy matter to so group the cases that a series of types of 
epilepsy could be definitely formed, and an instructive 
lesson in treatment and prognosis be acquired. It was with 
the hope of establishing some basis for the selection of 
cases for treatment that the observations on which this 
paper is founded were made. The results of months of 
patient work was far from gratifying in many respects, but 
sufficient information was gained to justify the trouble 
expended. 

In the cases herewith presented, the time during which 
observations were made and recorded varied from eight 
months to several years. Ninety of these cases were so lo- 
cated that they could be conveniently grouped for statistical 
purposes and comparison, while the others were selected 
for the special features of their disease. I am indebted to 
Dr. Charles C. Flint, of Lenox, Mass., for the compilation 
of the table showing daily movement in ninety cases during 
a period of eight months. This time really represented a 
year, for in the four months remaining nothing of an excep- 
tional nature occurred to qualify the record. The disease 
had been established for not less than one year in any case, 
and in a few cases it had existed upwards of twenty years. 
During the period mentioned, no epileptics had a few 
more than 11,000 distinct epileptic siezures. These were, 



I 66 FRANK H. INGRAM. 

in the main, well denned convulsions ; a few were vertigin- 
ous attacks of mild form, without spasms of the limbs ; 
others were pure motor explosions of a non-convulsive 
type. A good majority of these seizures occurred during 
the day, as will be seen by reference to the following record 
of ninetv cases : 



Month. 


May 


June 


July 


Aug. 


Sept. 


Oct 


Nov. 


Dec. 


Total. 


Diurnal 

Nocturnal... 


738 

530 


1042 
855 


666 
475 


726 

501 


793 
502 


956 
444 


843 
352 


886 
447 


5750 
4106 


Total 


1268 


1897 


1141 


1227 


1295 


1400 


1193 


1333 


9856 



Here we have a total of 9,856 epileptic seizures occour- 
ing during a period of eight months. Within this time, five 
of the patients died or were discharged from care, so that 
at all times there was an average of eighty-five under 
observation. It will be noticed that the monthly average 
was 1,232, 718.75 diurnal, and 513.25 nocturnal seizures ; 
for each patient, 14.495, 8.547 diurnal, and 6.038 nocturnal. 
In June the average was much higher, being 22.31+ for 
each patient, 12.25+ diurnal, and 10.05+ nocturnal; and 
the difference between the diurnal and nocturnal seizures 
was less than in any other month. It is an interesting fact 
that during this month there were many marked thermom- 
etric and barometric changes : hot days would be followed 
by exceptionally cold nights, and the transitions from dry 
to wet weather were remarkable. It seems that these 
atmospheric variations must have had a prominent influ- 
ence in producing the excess of convulsions ; and in the 
only other month in which the number of seizures was 
above the average, namely, October, there was one week 
of similar conditions. Sudden barometric changes invari- 
ably caused an increase in the number of convulsions, and 
before and after a thunder storm this was excessive. 
Changes of temperature did not exert such a marked 
influence. 

The excess of diurnal over nocturnal fits may be ac- 
counted for by the fact that at night many causes of excite- 



THE STUD Y OF EPILEPS Y. j6j 

ment are absent. The external influences which affect 
the emotions are wanting, and the repose of the body is 
unfavorable to the development of motor spasms. With 
the exception of the one month in which the many noc- 
turnal seizures were charged to the account of atmospheric 
influences, undigested food, retained urine, and bad dreams 
were I believe, responsible for a vast majority of the fits. 
I have frequently noticed that a convulsion coming closely 
upon the evening meal, the patient being soon put in bed, 
would be followed by one or more convulsions during the 
night; and, in such cases, it was a convenient inference 
that the first explosion retarded gastric digestion and that 
the presence of food in the stomach was sufficiently irrita- 
ting to renew the spasms. 
With the urine of several hours of excretion in the bladder, 
a fit at the time of, or soon after, retiring, would be followed 
by others before the night had passed. In the same cases, 
when the urine had been voided before the fit, a tranquil re- 
pose would, as a rule, mark the night. 

Disturbing dreams were not impotent so far as the seiz- 
ures were concerned. It was often observed that a patient 
would awaken with a start, and almost immediately after 
have a well defined convulsion. In these instances the 
circumstances were such as to exclude the probability that 
the startled awakening from sleep was the beginning of the 
epileptic seizure. With the more demented patients, con- 
stipation and retention of urine were habitual, so that two 
exciting causes of convulsion were ever present. 

The aura epileptica was defined in less than one-half of 
the cases under observation. More frequently the fit was 
sudden and ushered in by loss of consciousness, the spasms 
of the limbs following after an appreciable interval. 

The stage of convulsion varied in duration from thirty 
seconds to as many minutes. The greatest violence was, 
as a rule, manifested at the middle of the attack, although 
sometimes most prominent at the beginning, or at the ter- 
mination, of the spasms. 

The periods of coma or stupor lasted from a few minutes 
to several hours. Occasionally there would be a series of 



I 68 FRANK H. INGRAM. 

apparently voluntary, but decidedly irrational, acts before 
consciousness was regained. This is well illustrated in two 
cases, as follows : 

A man, twenty-five years of age, had had epileptic 
seizures with varying frequency during a period of ten or 
eleven years. As a boy of from thirteen to fifteen years, he 
masturbated almost incessantly, not because of a develop- 
ing sexual desire, but for the reason that there was a 
peculiar irritation of the genitals, which was relieved only 
by friction of the parts. His foreskin was long and adher- 
ent, and circumcision was performed, with some benefit to 
the sufferer. The epileptic seizures in this case were of the 
ordinary kind up the time of emergence from stupor. At 
the period when consciousness should have returned, this 
man would arise from where he had been placed, would 
wash his face and hands and carefully adjust his disordered 
garments, then, with gravity of countenance and dignity of 
demeanor, perform ludicrous but pitiable acts. He would 
disarrange the furniture and ornaments of his room, or 
would urinate in a vase or between the matresses of his 
own or a fellow-patient's bed. His appearance indicated 
consciousness, but he had no recollection of these acts, and 
a careful observation of the case demonstrated that he was 
not conscious when performing them. Some months this 
patient would have five or ten fits and fifteen or twenty 
nocturnal emissions of semen ; again, this order would be 
reversed. There was ever a definite relation between the 
fits and the emissions, and the latter probably represented 
localized epileptic spasms. 

The second patient of this class, a man twenty-one years 
of age, had had epilepsy for eight years. His seizures con- 
sisted of, in the order named, stupor, rolling of the body 
from side to side, with mild spasms of the limbs ; somno- 
lence ; extreme terror, accompanied by violence in action ; 
exhaustion and gradual return of consciousness. During 
the period of terror, he would run at highest speed for a 
mile or two miles, vaulting fences and other obstructions 
with an unnatural and surprising agility ; or he would 
expend his violence in tearing boards from their fastenings 



THE STUD Y OF E PILE PS Y. I 69 

or in chopping wood with an axe. The stage of exhaustion 
would last ten or fifteen minutes, during which the patient 
would stagger about in a feeble way, or he would seat him- 
self or lie down in some convenient place. Consciousness 
returned slowly. 

Another case, in some respects similar to the two just 
described, was an unmarried woman, twenty-five years of 
age. Frequently she would have the most common form 
of epileptic seizure, but fully as often her disease would be 
manifested in unconscious acts of extreme violence, with- 
out convulsions, which would be succeeded by somnolence 
or stupor. She did not remember what had occurred dur- 
ing her paroxvsms of violence. 

A case deserving at least a passing notice was a woman 
thirty-eight years of age. Her epilepsy consisted of infre- 
quent nocturnal convulsions, always attributable to an 
undigested supper, and of frequent attacks of petit mal or 
vertigo. The vertiginous attack was a simple, momentary 
loss of consciousness ; the other form of seizure consisted 
of loss of consciousness, accompanied by incoherent mut- 
terings, which would last from thirty seconds to three 
minutes. In these there would be apparently but a sus- 
pension of continuity of mental a;tion, for, na matter 
whether, at the onset, the patient had been reading, knit- 
ting or engaged in conversation, with the return of con- 
sciousness the train of thought would be taken up at the 
broken point and carried out in orderly sequence. This 
one feature, of itself, makes a conspicuous departure from 
the usual form of attack of petit mal. This patient was 
anaemic and suffered from constipation and hemorrhoids. 
Tonic treatment and ligation of the piles caused a most 
marked improvement, but a cure was not effected. In this 
case there was a partial amnesia, which, in degree, was dis- 
proportionately more severe than the fits. 

The most peculiar character of convulsion witnessed in 
any case was a combination of almost every conceivable 
motion of the body and limbs. After a cry and a twisting 
of the body, the patient, a woman, twenty-three years of 
age, would fall to the floor ; the top of the head would be 



I -o FRANK H. INGRAM. 

fixed as a pivot ; the body would rotate and, at the same 
time, describe a circle 'with its length as the radius; the 
limbs would engage in a series of clonic convulsions of 
greatest severity, and the fit would terminate in a tonic 
rigidity of all the muscles, which would be followed by 
relaxation and stupor. Exhaustion was not as marked in 
this case as might have been expected, considering the 
violence of the explosion, and the mind cleared quickly. 

I have the records of three autopsies in which the 
changes in the brain would fully account for the epileptic 
convulsions. These are given with such parts of the histo- 
ries of the cases as are pertinent. 



Case I. — A .woman, forty-five years of age, had been 
afflicted with epilepsy for more than ten years. The 
seizures were frequent, often as many as six occurring in a 
day. Towards the end of life the fits were most severe, 
and death occurred from exhaustion a short time after 
emergence from the epileptic state. The fits were invari- 
ably of a kind : spasms of the left leg, spasms of the arm of 
the same side, loss of consciousness and convulsions of the 
limbs of both sides. For a short period after each fit, the 
left side appeared weaker than the right side. 

The mental state of this woman had a history not un- 
common in epilepsy. Some three years after the develop- 
ment of the disease, she manifested considerable irritability 
and had frequent outbursts of marked excitement. Event- 
ually the excited periods increased and a well-defined 
mania developed. Paroxysms of violence were frequent 
and delusions were wanting. As years passed, excitement 
was less marked and the mind became sluggish, but de- 
mentia was not complete. 

The post-mortem examination showed a poorly nour- 
ished body. The heart-walls were thin and the ventricles 
dilated, but there was no evidence of disease of the lungs 
or of the abdominal viscera. In the right hemisphere of 
the brain, the subcortical vessels of the "leg-centre" were 
dilated and tortuous, presenting the appearance of multiple 
aneurisms. This condition, so much in keeping with that 
of the heart, was found in no other part of the brain, and it 
will, I believe, fully account for the peculiar character, as 
well as for the existence, of the convulsions. 



THE STUD Y OF E PILE PS Y. I 7 I 

Case II. — A man, thirty-two years of age, was suddenly 
seized with loss of consciousness and paralysis of the left 
side of the face and body. The recovery from the hemi- 
plegia was rapid, but there was a subsequent deafness and 
a paresis of the face and tongue on the left side, and 
epilepsy soon developed. The convulsions always began, 
were more violent and of longer duration on the left side. 
Death terminated the disease, after twenty-four hours of 
convulsions and coma, in the fourth year. 

The post-mortem examination of the brain showed 
deposits of caseous matter, in the form of granules, in the" 
sheath of each auditory nerve and between the skull and 
dura and between the dura and pia, in the right Rolandic 
region. The pia was, in this area, fixed to the brain by 
fibrinous and caseous matter, and the blood vessels were 
coated with similar substances. There was a slight cortical 
degeneration, probably a softening caused by pressure of 
the deposits, but the other parts of the brain were normal. 

Case III. — The history of this case is unimportant, ex- 
cepting that the convulsions were synchronous on the two 
sides of the body. The autopsy revealed an area of de- 
generation in the posterior horn of each lateral ventricle. 
This is the only case in my experience, although much care 
has been taken in many examinations, in which there was 
an indication of lesion in the so-called epileptogenic zone. 

When we view epilepsy in its various phases, observe 
the many ways in which it manifests itself as to the charac- 
ter of the convulsions, and note the different findings in 
post mortem examinations of the brain, it would not be 
reasonable to expect to discover a definite pathology for 
this disease Cortical and ventricular degenerations, vari- 
ous kinds of deposits, varicose and aneurismal vessels will 
be found singly or in combination. Various kinds of dis- 
orders of nutrition and vascular weaknesses are frequently 
the only apparent defects in cases of epilepsy. Psychic 
influences are most potent in generating the explosions. 

In conclusion, a few words in regard to the treatment of 
epilepsy. The patients of whom I have written have been 
under medical care at all times, some in hospitals and 
others at home. About one-half took bromides ; the re- 
maining ones took various other drugs. The bromides in 
some instance greatly reduced the number of convulsions, 



I72 FRANK H. INGRAM. 

but nitro-glycerine, iron, digitalis, and other drugs did 
almost as much good. The bromides seemed especially 
adapted to some cases, but their ultimate effects were fre- 
quently so undesirable as to materially affect the value of the 
drug. 

The tendency of epilepsy is toward dementia, more or 
less complete. It would, therefore, seem fitting that the 
physician should select remedies which will correct any 
functional disturbance in the circulatory, digestive or uri- 
nary systems, and that he should avoid, unless particularly 
indicated or absolutely demanded, those restraining reme- 
dies which, long continued, impoverish the blood and 
hasten mental degeneracy. 



ANTIPYRIN IN ANGINA PECTORIS. 

The "Epitome" (Dec, 1889) notes the good effects of 
this remedy in severe angina pectoris. The patient was 
brought into the ward unconscious, morphine and trinitrine 
having been administered. When Dr. E. D. Martin (New 
Orleans) first saw him, he was undergoing much agonizing 
pain, that five drops of nitrite of amyl (by inhalation) magi- 
cally relieved. Large doses of antipyrin and digitalis were 
ordered three times daily, with a view of diminishing the 
reflex functions. On the third day the antipyrin was 
stopped ; but on the fourth pain returned, and the same 
treatment was again employed for ten days, with flattering 
results. A striking feature of the report is the patient's own 
intelligent history of the case, the procedure instituted by 
Dr. Martin for his relief corresponding exactly to his own 
method of diminishing torture and one that he had followed 
for five years. Earlier, he had used chloral during, and 
bromide of potassium after, the attack. There existed 
strong hereditary predisposition to angina pectoris, all of 
the patient's family suffering more or less from the same 
trouble. L. F. B. 



REPORTS OF SIX CASES OF FRIEDREICH'S 
ATAXIA, OCCURRING IN THREE DIF- 
FERENT FAMILIES. 

By DR. CHARLES W. ROOK, of Quincy, 111., and DR. CHARLES L. 
DANA, of New York. 

THE histories of the first four cases were sent to me, 
with photographs, by Dr. Rook. The histories given 
leave no doubt in my mind that they are true cases 
of Friedreich's ataxia. 

To them I have added one case, recently observed by 
me, and a second, which was sent to me by Dr. J. W. S. 
Gouley, and which has been under my observation for sev- 
eral years. This latter patient's history was reported in 
brief in the " Medical Record," of October i, 1887. It will 
appear soon, in full, in an article on Friedreich's ataxia, by 
myself, in Keating's " Cyclopaedia of Children's Diseases." 
I therefore omit the publication of the case here. Some 
comments upon the disease, and some new observations 
made upon my cases, have been embodied in the article 
referred to, and cannot properly be published now. 

I find that there have now been reported about 165 
cases, Fifty-four, or one-third of them, have been reported 
by seventeen different American observers. I conclude 
that Friedreich's Ataxia is a relatively frequent disease in 
this country, 

C. L. D. 

HISTORY OF DR. DANA'S CASES. 

Case I. — B. X., United States, aged twelve. One paternal 
uncle had some spinal trouble ; one paternal aunt had some 
spinal trouble, and wore braces from tenth to forty-fifth 
year ; father had some spinal trouble, and walked ataxic in 
last ten years of life, when he died of pneumonia. Patient 
is youngest of four children : one boy, twenty-four ; one 
boy, twenty; one girl, fifteen — all of whom are well. 



174 CHAS. IV. ROOK AXD CHAS. L DANA. 

Birth natural, at full term. He seemed well until his 
seventh year, when he had scarlet fever. Has been in 
poorer health since, but no especial trouble was noted until 
the present one developed. No history of diphtheria. He 
had whooping-cough in the spring of 1888. In the follow- 
ing winter of 1888-89 ne was noticed to stumble in his gait 
while playing, and especially to stumble in the dark. His 
gait was awkward and irregular. He complained of no 
pain in the legs, but had some pains in head and stomach 
occasionally. Xo bladder or rectal troubles, and no dis- 
orders of vision or speech were complained of. 

He was sent to Dr. S. X. Phelps, hip-disease being sus- 
pected. Dr. Phelps excluded any such trouble, and referred 
him to me, October 16, 1889. 

When examined by me he showed a gait somewhat 
ataxic and stumbling, but also with an apparent limp in the 
right leg. He could not walk far with the eyes closed, nor 
could he stand with the eyes closed and the feet together 
except for a short time. He was well grown, the legs being 
a little small, but not showing any local atrophy or hyper- 
trophy. His speech was somewhat peculiar; but this it had 
always been. Xo nystagmus ; vision and optic nerves 
normal. His knee-jerks were present. Slight bactile an- 
aesthesia over right foot, and dorsal flexion of right great 
toe were noted. Urine normal; electrical reactions normal. 

He had no pain ; no spinal curvature. Essentially his 
trouble was only an ataxic gait; the arms not being affected. 
This ataxia was very apparent, however, and was worse in 
the dark; so that though clumsy in gait at all times, he 
was especially so at night. 

The case is in its incipient stage, and all the symptoms 
are not present ; but, in view of the dominance of ataxia 
and the family history, there seems to be no doubt of the 
correctness of the diagnosis. 

Case IV. — J. D., aged twenty-one, United States. Xo 
family history of ataxia or other nervous disease. It devel- 
oped at the age of fifteen, after a blow on the head, and 
was associated with polyuria and speech - disturbances. 
The ataxia and the peculiar rolling gait are very marked. 

HISTORY OF DR. ROOK'S CASES. 

Their maternal grandfather died of phthisis at the age 

of seventy years. Their grandmother is sixty-eight years 

old, and enjoys good health. To them were born eight 

children. One son died in convulsions when nine months 



FRIEDREICH'S A TAXlA. I ~ - 

old, and another of phthisis at the age of twenty-two years. 
Three sons, in good health, with families in which no ataxia 
has developed. The three daughters have good health. 
One is single ; one is married seven years, but has no 
children ; and one, the mother of my cases. She is of 
medium build, and forty-three years old. She has had no 
serious sickness. Intoxicants, chiefly beer, are employed as 
a beverage in the family of the latter. 

In the family history there are no instances of consan- 
guinity, syphilis, insanity, or ataxia. The only predispos- 
ing causes revealed are phthisis and alcoholism. 

To Mr. and Mrs. G,, parents of my cases, were born 
eight children, as follows : 

ist. Julia, aged twenty years, ataxic since the age of 
eleven years. 

2d. Laurence, aged eighteen years, not ataxic. 

3d. Antone, aged sixteen years, ataxic since the age of 
eleven years. 

4th. Clara, aged fourteen years, ataxic since the age of 
eleven years. 

5th. Katie, aged twelve years, not ataxic. 

6th. Bertha, aged nine years, ataxia developing. 

7th. Infant daughter, died of whooping-cough at the age 
of sixteen months. 

8th. Infant daughter, died of inanition at the age of 
seventeen months. 

Case I. — Julia G., aged twenty years. Her early life 
was very free of sickness. In her second year she had some 
fever during dentition ; and in her eleventh year an attack 
of measles, from which she recovered without complica- 
tions. 

During her eleventh year she first experienced a sense 
of weakness in the lower limbs, and in a few months her 
gait became staggering. These symptoms gradually in- 
creased till she was unable to walk or stand without sup- 
port. Her arms were affected one year later, or during her 
twelfth year. Since the commencement of this disease she 
has had no other sickness. 

She is now much deformed by contractures. There 
exists a kyphosis, a left dorsal and a right lumbar scoliosis, 
a double talipes valgus ; when at rest, the hands assume a 
wrist-drop and the fingers a claw-like appearance. 



176 CHAS. W. ROOK AND CHAS. L. DANA. 

She is not well nourished, though the food taken is 
digested without distress. Physical examination of lungs 
and heart negative. Respiration 18 and the pulse 80 per 
minute. Urine, reaction acid, sp. gr. 1.020, and contained 
no morbid elements. 

The mammae are partially developed, and the menses 
have thrice occurred, at intervals of two or three months, 
during this her twentieth year. 

The expressionless appearance of her face is less marked 
when attentively listening to or engaging in conversation. 
When reading she pronounces slowly yet distinctly, but in 
conversation her speech is slower, voice more tremulous, 
and acts of cerebration are performed with an effort. She 
has a good memory, as shown by the fact that she can yet 
instruct her brothers and sisters in reading and mathematics, 
though it is eight years since she was at school. 

Her sleep is natural in appearance, though she requires 
from nine to fourteen hours daily. Her disposition is be- 
coming more irritable- than in the earlier years of her 
affliction. 

Decided atrophic changes have occurred throughout the 
entire muscular system. No muscles are paralyzed, though 
their electrical reaction is much less than normal. 

Co-ordination is very deficient, more so in the lower 
than upper extremities. Though unable to stand or walk 
without support, ataxia of station is probably increased by 
closure of her eyes, for then the movements of her arms 
become more unsteady. 

She is able to feed and dress herself and perform some 
work, as the washing and drying of dishes and sewing. 
Several minutes are required for her to thread her needle, 
and then only by supporting one hand with the other. 

She has some attacks of vertigo, usually soon after rising 
of a morning or after meals. She often experiences a feel- 
ing of numbness in her limbs, but no pain. 

Cutaneous sensibility is diminished, particularly in the 
lower limbs, where two points of pressure maybe separated 
as much as four inches and described as only one point of 
pressure. 

Her vision is good, no nystagmus, and ophthalmoscopic 
examination of the eyes negative. 

The sense of hearing, taste, and smell normal. Super- 
ficial reflexes, as the plantar, are diminished. Ankle clonus 
and patellar reflexes absent. 

The extremities are colder than natural, but not oedema- 
tous. No secretory disturbances, save that of the menses. 



FRIEDREICH'S A TAXI A. I 7 7 

CASE II. — Antone G., aged sixteen years. When 
seven years old he had measles, from which he recovered 
without complications. During his eleventh year his 
parents first noticed his staggering gait, and about one year 
later his arms became affected. 

There now exist no contractures except a marked ky- 
phosis, which can be partially overcome at will, and a 
double talipes valgus. 

His gait is very ataxic, the feet being separated some 
six or eight inches in order to better maintain his equi- 
librium while standing or walking. 

Over slight obstructions he stumbles, occasionally fall- 
ing ; yet, notwithstanding this difficulty, he has, during this 
year, taken many walks of two or three miles. 

His nutrition is good, and the functions of the primae 
viae are normal. 

Physical examination of lungs and heart negative, though 
he has frequent attacks of palpitation. 

On three occasions were witnessed attacks of syncope 
that are worthy of record. The first attack occurred while 
in the Sayre suspension-apparatus ; second, while standing 
and being examined for spinal curvature ; and third, while 
sitting and being examined to determine the electrical 
reaction of the muscles. 

The strength of current employed, that induced the last 
attack, was only sufficient to produce, with the electrodes 
placed on the right arm, at elbow and wrist, very slight 
flexion of the hand. 

He would announce the onset of the attacks by the 
remark. " I feel so dizzy." His head would sway from side 
to side, face become pale, radial pulse disappear, muscles 
relax, and unconsciousness supervene. 

The relaxed condition would continue for possibly half 
a minute, during which time the pulse and respiration were 
not perceptible ; then followed a sudden and violent tonic 
convulsion, his body assuming a position of extreme opis- 
thotnos. In about one minute the convulsive state began 
to relax, consciousness returned, and for some minutes he 
suffered severe pain in the erector spinas muscles. During 
the seizure the pulse and respiration returned, the lat- 
ter being stertorous, and the kyphosis completely dis- 
appeared. 

Temperature is normal, respiration 19, and pulse 84. 

The urine is acid in reaction, specific gravity 1.025, an< ^ 
contained no morbid elements. 

His intellect is but little affected, memory good, speech 
slow, voice tremulous, and facial expression habitually 
gloomy. 



I 78 CHAS IV. ROOK AXD CHAS. L. DANA. 

His sleep is natural, save when occasionally disturbed 
by spasmodic contractions of the lower limbs. These.con- 
tractions are painless. 

No paralysis or atrophy exists. Electrical reaction of 
muscles diminished. 

His power of co-ordination is much less than normal ; 
yet, under direct supervision of sight, he has fair control of 
his extremities. With eyes closed, the ataxia is more ap- 
parent, for then he can neither stand nor walk without 
support. 

He has frequent attacks of vertigo, always preceding 
attacks of syncope. He experiences no pain, save after the 
convulsive seizures, but often has a feeling of numbness in 
the extremities. 

Cutaneous sensibility less than normal ; more noticeable 
in lower extremities, where he cannot distinguish between 
two points of pressure, if separated three or four inches ; 
nor can he correctly locate a point of pressure. 

Vision is good, and ophthalmoscopic examination of the 
eyes negative. 

Sense of hearing, taste, and smell normal. 

Plantar reflex diminished. Ankle clonus and patellar 
reflex absent. 

The only secretory disturbance has been an occasional 
incontinence of urine. 

There are no vaso-motor changes. 



Case III. — Clara G., aged fourteen years. When two 
years old she had an attack of pneumonia, and has since 
remained delicate. At five years of age she had measles, 
and recovered without complications. 

During her eleventh year the ataxia began in the lower 
limbs, and within a year the arms were also affected. 

The first objective symptom noticed was her staggering 
gait ; she also early experienced a sense of weakness in the 
limbs. 

Her gait is now very ataxic, as are also the movements 
of her arms. In passing through a room she will touch one 
or more pieces of furniture, thereby enabling her to better 
maintain her equilibrium. 

There exist some contractures, as a kyphosis, double 
talipes valgus, and wrist-drop, all of which can be partially 
overcome. 

She has a dry, hacking cough, and auscultation reveals 
the presence of numerous crepitant rales in each lung, but 
more abundant in the posterior part of the lower lobes. 



FRIEDREICH'S A TAX I A. I 79 

The heart's action is very irritable, hastily crossing a 
room causing palpitation for several minutes. 

Her temperature, as shown by a thermometer, is usually 
above normal, though the extremities feel colder than 
natural. There is frequent flushing of one or both cheeks. 
This increase of temperature and hectic is due to the dis- 
eased condition of the lungs. 

Respiration 21, pulse 90. 

Urine is acid, with a specific gravity of 1.024, and in 
other respects nurmal. 

Her facial expression is more intelligent than her sister 
Julia's or brother Antone's, for it is not melancholic. 

She learns easily, has a good memory ; speech slow and 
voice very tremulous. 

Sleep is natural. 

Co-ordination very much diminished. She cannot walk 
in a straight line with eyes open, or stand with feet together 
without her body swaying, and will fall, if not supported, 
when her eyes are closed. 

The ataxia is nearly as marked in the upper as in the 
lower extremities. When extending the hand to grasp an 
object, its claw-like appearance is quite noticeable. 

Electrical reaction of muscles diminished. Atrophic 
changes are marked throughout the muscular system. 

No muscle or group of muscles is paralyzed. 

She has frequent attacks of vertigo, and is occasionally 
disturbed by a feeling of numbness in the lower limbs, but 
has no pain. 

Cutaneous sensibility is diminished. Not able to locate 
or distinguish between two points of pressure any better 
than her sister or brother. 

Ophthalmoscopic examination of her eyes negative. 
Vision is good. Some months ago nystagmus was quite 
marked ; now it is only occasionally observed. 

Her sense of hearing, taste, and smell normal. 

Plantar reflex diminished. Ankle clonus and patellar 
reflex are absent. 

There are no secretory disturbances. 



Case IV. — Bertha G., aged nine years. At the time 
of her birth the other children of the family were sick with 
the measles, and nine days later a cough developed and a 
slight eruption appeared. 

She was supposed to have had the measles, When one 
and a half years old she had convulsions, and once or twice 
yearly the attacks recurred till she was six years old. The 



I g CHAS. IV. ROOK AXD CHAS. L. DAXA. 

later attacks are known to be due to indigestion, and prob- 
ably the earlier ones also. 

When she was seven years of age she had the measles, 
there being at that time an epidemic of this disease ; but no 
other member of the family was attacked. 

A slight deafness was observed after her recovery ; and 
two months later there suddenly appeared, at each ear, a 
profuse otorrhcea, which ceased in a few weeks, leaving her 
almost entirely deaf. 

She is now in good health, there being no derangement 
of the digestion, heart, lungs, or kidneys. 

Her disposition is pleasant, and her face bright and intel- 
ligent. Speech is slow, but not tremulous. Sleep is natural. 

Ataxia of locomotion or station is not apparent with eyes 
open, but with them closed her gait and station are each 
unsteady. 

In the excitement of play, or when eyes are closed, the 
motion of her arms is also slightly ataxic. 

There are no muscles atrophied, contractured, or para- 
lyzed. Electrical reaction of muscles normal. Tactile 
sensation diminished. Vision, taste, and smell normal, but 
hearing destroyed. 

Plantar reflex nearly normal. Ankle clonus absent, and 
patellar reflex present, but greatly diminished. 

There are no vaso-motor or secretory disturbances. 

The treatment employed for these patients has been, for 
each : silver nitrate, one grain, in pill, twice daily ; for 
Cases I. and III., cod-liver oil in emulsion, and, for all, 
suspension. For six months an average of two suspensions 
per week have been given. 

Results of Treatment. — The general health of Cases I. 
and III. are improved, but no change noted in their ataxia. 
Case II. is improved in his gait, but not in his reflexes or 
tactile sense. Case IV. : Ataxia not increased during six 
months' treatment. 



REPORT OF THE COMMITTEE OF THE NEW 

YORK NEUROLOGICAL SOCIETY UPON THE 

GALLUP LUNACY BILL. 1 

Mr. President : 

The Committee, appointed at the last meeting of the 
Neurological Society to examine the proposed new lunacy- 
law, known as the Gallup Bill, beg ieave to report as 
follows : 

The measure has a large number of very excellent 
features, which, if they should become law, would prove of 
the highest advantage to the unfortunates whom they are 
intended to benefit. These are the sections relating to 

i. The removal of the insane to asylums by attendants 
of the same sex. 

2. The admission and discharge of voluntary patients. 

3. The admission of emergency cases without papers of 
any kind for three days. 

4. The forbidding of the confinement of insane persons 
in jails in the same room with criminals, and any detention 
beyond ten days. 

5. The provision of home visits of indefinite duration at 
the discretion of the medical officers of the asylums. 

6. The boarding-out of suitable chronic lunatics in pri- 
vate families, at county expense, according to the systems 
in vogue in Scotland and Massachusetts. 

Aside from the invaluable particulars just described, there 
are several sections relating to commitment to which there 
would seem to be serious objections. 

In order to more fully comprehend the changes that it 
is proposed to make in the present law regarding this pro- 

1 Presented at the Meeting of February 4, 1890. 



1 8 2 THE GALL UP L UNA C Y BLLL. 

cedure, the law now in force, dating from 1874 (chap. 446), 
is here given, together with the most important sections of 
the Gallup Bill relating to the same matter : 

Laws of 1874. 

" Title i, § 1. No person shall be committed to or con- 
fined as a patient in any asylum, public or private, or in any 
institution, home or retreat for the care and treatment of the 
insane, except upon the certificate of two physicians, under 
oath, setting forth the insanity of such person. But no 
person shall be held in confinement in any such asylum for 
more than five days, unless within that time such certificate 
be approved by a judge or justice of a court of record of the 
county or district in which the alleged lunatic resides, and 
said judge or justice may institute inquiry and take proofs as 
to any alleged lunacy before approving or disapproving of 
such certificate, and said judge or justice may, in his dis- 
cretion, call a jury in each case to determine the question of 
lunacy. 

" £2. It shall not be lawful for any physician to certify 
to the insanity of any person for the purpose of securing his 
commitment to an asylum, unless said physician be of 
reputable character, a graduate of some incorporated medi- 
cal college, a permanent resident of the State, and shall 
have been in the actual practice of his profession for at least 
three years, and such qualifications shall be certified to by 
a judge of any court of record. No certificate of insanity 
shall be made except after a personal examination of the 
party alleged to be insane, and according to forms pre- 
scribed by the State Commissioner in Lunacy, and every 
such certificate shall bear date of not more than ten days 
prior to such commitment. 

" § 3. It shall not be lawful for any physician to certify 
to the insanity of any person for the purpose of committing 
him to any asylum of which the said physician is either the 
superintendent, proprietor, an officer, or a regular profes- 
sional attendant therein." 

The Gallup Bill. 

" £ 3. Whenever a justice of the peace or a superintend- 
ent of the poor or a judge of a court of record shall receive 
information that a certain person, deemed insane, should be 
placed in custody, for either of the causes stated in section 
first of this act (Form B), the said justice or superintendent 
or judge shall, by an order in writing (Form C), direct two 






THE GALLUP LUNACY BILL. 183 

examiners in lunacy to examine the alleged insane person 
and report to him within one day, exclusive of Sunday, after 
their respective examinations (Form D) the results of such 
examination, with their recommendation as to the special 
action necessary to be taken in the case ; if a justice of the 
peace, or a superintendent of the poor, issues the order for 
an examination, he must personally visit the alleged insane 
person ; if the physicians certify that the person so exam- 
ined is not insane, the justice or superintendent shall dis- 
miss the case, but if they certify that he is insane, and a 
proper subject for commitment, as provided in section one 
of this act, said justice or superintendent shall certify, under 
his hand, to the correctness of the proceedings and to his 
personal visit (Form E), and shall cause said certificates to 
be delivered to a judge o r a court of record within two days, 
exclusive of Sunday, of the date of the last certificate made, 
which last certificate must not bear date of more than two 
days of the first certificate. 

" §4. On receiving said certificates from a justice of the 
peace or superintendent of the poor, or on receiving the 
certificates of two examiners in lunacy appointed by him- 
self, certifying to the insanity of any person, and recom- 
mending that he be placed in custody for cause, then and in 
either case the said judge may or may not visit the alleged 
insane person, or require that he be brought into court, but 
he shall state in the order of commitment whether or not he 
saw him, and if he did not see him he shall give the reason 
therefor ; the judge may or may not take further testimony, 
and he may call a jury, but in either case, if satisfied that 
the person is insane, and that the reason given for his'com- 
mitment in the certificates are just and right, he shall make 
an order (Form F), committing said person to the custody 
of the superintendent of the proper State asylum for the 
insane, or the keeper or superintendent of a private asylum 
or licensed house for the insane ; said order shall be issued 
within five days after the date of the last medical certificate ; 
a copy of said medical certificates and answers, obtained in 
accordance with Form D, shall be transmitted with the 
order of commitment to the superintendent of the respec- 
tive asylum, and the originals thereof shall be filed in the 
office of the clerk of the county, and shall be inaccessible 
except on the written order of a judge of a court of record ; 
nothing in this section shall be construed to prevent the 
commitment of an insane person, in accordance with the 
provisions of this act, to the asylum of any county author- 
ized by law to have the care of the acute and chronic insane, 



! 84 THE GALLUP LUNACY BILL. 

provided the said insane person is a legal resident of said 
county. 

" § 5. It shall be the duty of the judge, before he makes 
the order of commitment, to cause the alleged insane person 
to be fully informed of the action about to be taken concern- 
ing him ; and if said insane person, or his friends or relatives, 
demand that other testimony be taken, or that a jury be 
called, the judge shall act at his discretion, but if he deny the 
motion, he shall state the reasons therefor in the commit- 
ment." 

To present a clearer view of all of the practical differ- 
ences in the two methods of commitment, they are con- 
densed and paralleled for comparison, as follows : 

Present Law. The Proposed Law. 



The family physician calls in an- 
other physician. Together they make 
out two medical certificates and swear 
to them before a notary. 

(This is all sufficient for admission 
to the asylum for five days.) 

A judge of a court of record must 
write his name and the word ap- 
proved on the back of the certificates 
to make them valid beyond the five 
days. 

The papers must not be over ten 
days old when the patient is ad- 
mitted. 



The family physician makes out a 
formal paper notifying a judge, jus- 
tice of the peace or superintendent of 
the poor that a patient of his is insane 
and a proper subject for an asylum. 

The official thus notified fills out 
1 two blank forms directing two physi- 
cians to examine the patient. 

The physicians make out two med- 
ical certificates, which are returned 
to said official. 

If the officer notified be a justice of 
the peace or superintendent of the 
poor, he must himself also visit the 
patient and satisfy himself as to his 
insanity, after receiving the certifi- 
cates of the physicians. He then 
makes out himself a corroborating 
certificate, and presents the three 
certificates to a judge of a court of 
record. 

The judge then sends notice to the 
patient of the proceedings, makes out 
an order committing him to the asy- 
lum, and finally issues a warrant to 
the asylum superintendent to send 
for the patient, or to a county official 
to remove him thither. 

The judge must also cause copies 
of the medical papers to be filed in 
the office of the county clerk ; and he 
must furthermore take proof as to 
the estate of the patient, filing another 
certificate as to these facts with the 
county clerk. 

The process is only completed after 
a formal paper has been made out 
by the asylum superintendent to the 
judge committing the patient, notify- 
ing him of the admission of the case. 
The judge must cause this paper also 
to be filed with the other papers in 
the office of the county clerk. 



THE CALL UP L UNA C Y BILL. I 8 5 

At present two papers only are necessary for the com- 
mitment of a patient to a hospital for the insane. Accord- 
ing to the law proposed thirteen papers will be required ; 
and simplified as much as possible by avoiding the lower 
officers and applying directly to the judge of a court of 
record, twelve papers, according to forms prescribed in the 
bill must be made out before the legal process is accom- 
plished. 

The objections to this form of procedure are : 

1) It is unnecessarily complicated. It may be carried 
out in country districts with a fair degree of patience and 
labor ; bet the difficulties of perfecting the process in the 
larger cities, and particularly in New York and Brooklyn, 
will be almost insurmountable. We are credibly informed, 
in fact, that some of our city judges who have seen the bill 
have expressed their unwillingness to have anything to do 
with a method involving so much of their valuable time, 
and will probably refuse to commit patients at all. 

2) The position of Examiner in Lunacy will be degraded 
to a reward for political labors, since the appointment of 
the two physicians in each case is left to the discretion of 
the county officials or judge, and not as now to the wishes 
of the family concerned. 

3) A majority of the patients will suffer harm from the 
visitation of two strange physicians, the visitation of the 
county official or judge, and the visitation of an officer of 
the court with a notification of the legal proceedings about 
to be instituted. 

In contradistinction to these facts we have abundant 
testimony to the effect that simple in comparison as is the 
existing law of commitment, no person has ever been, 
through intentional wrong-doing, placed in an asylum as 
insane in this State, the present method affording ample 
protection. 

But it is possible to make certain improvements in the 
law now in force, not only in the manner of commitment, 
but also in the means of regaining subsequent liberty ; and 



I 8 6 THE GALL UP L UNA C Y BILL. 

the suggestions your committee would submit are as 
follows : 

i) There should be no material change in the present 
mode of commitment by two medical certificates, sworn to, 
and approved by a judge of a court of record, as provided 
in the Laws of 1874. 

2) Emergency cases should be received for three days 
without papers of any kind, as specified in the proposed 
new law. 

3) The medical certificates should be more carefully 
and thoroughly made out, not only in justice to the patient, 
but also for the benefit of the asylum physicians, who now 
rarely receive many facts bearing upon the medical history 
of their patients or upon their mental condition. To this 
end the form prescribed in the Gallup Bill should be 
adopted. A few additional questions should be incor- 
porated in the medical certificate for the purpose of deter- 
mining whether the physicians have informed the patient 
of their intention of placing him in a hospital for the insane 
for treatment, in order to guard against the serious harm so 
often done to patients by removing them to an institution 
through deception. The State Commission in Lunacy 
seems to be invested with the power to prescribe the form 
in which the medical certificate should be made out, and a 
law regulating this would not appear to be necessary. 

4) There should be a section in the law permitting any 
higher justice, upon application from any patient in an 
asylum, to appoint at his discretion a commission of two or 
three p.hysicians to quietly examine said patient as to his 
mental condition, and upon receiving their report favorable 
thereto, to discharge him from the custody of the asylum. 
By the Laws of 1889, chap. 283, § 22, the State Commission 
in Lunacy is empowered to make such regulations as to 
the correspondence of patients as would ensure the proper 
carrying out of this law. 

5) A clause should be introduced into the bill providing 
that nothing in the lunacy laws of the State shall be con- 



THE GALL UP L UNA C V BILL. I 8 "] 

strued to interfere with the reception and treatment of 
acute cases of insanity in chartered general hospitals, in 
the same manner and under the same conditions as patients 
suffering from other diseases are there received and treated, 
provided such hospitals have suitable accommodations 
approved by the State Commission in Lunacy. 

(Signed) Frederick Peterson, 

Chairman. 

C. L. Dana, M.D., 
Ralph L. Parsons, M.D., 
Geo. W. Jacoby, M.D., 

Ex -officio. 



geriscope. 



By E. P. HURD, M. D , LOUISE FISKE-BRYSON, M. D., W. \V. SKIN- 
NER, M. D , GRACE PECKHAM, M.D., and ISAAC OTT, M.D. 

DELIRIUM TREMENS. 

At a recent meeting of the Imperial and Royal Society, 
of Vienna, (Jan. ioth, 1890), the subject of delirium tremens 
was discussed. 

PROFESSOR MEYNERT regarded this morbid entity as 
the result of a slow and chronic poisoning of the organism 
by alcohol. The attack is always preceded by great ex- 
cesses in the use of spirits or absinthe ; it may also be pro- 
voked by sudden suppression. It seldom comes on spon- 
taneously, being generally the accompaniment of an inter- 
current affliction: an haemoptysis, a pneumonia, a pleurisy, 
an epileptic fit, a traumatism ; simple mental emotion may 
serve as an exiting cause. In this respect it resembles the 
onset of hydrophobia. 

Delirium tremens presents a march of extreme regular- 
ity. Two distinct periods in its evolution are recognized. 
In the first, or period of anguish, the patient is a prey to 
an intense delirium of persecution; unlike other deliriums 
of the same nature, the danger which threatens the indi- 
vidual suffering from delirium tremens is immediate. The 



1 88 PERISCOPE. 

patient is afraid of being killed by thieves, and to escape the 
danger which is impending, he will sometimes attempt sui- 
cide. This period of anguish lasts about three days ; to this 
succeeds the second period or that of hallucinations and rest- 
less dreams. These toxic hallucinations may be of central 
or peripheral origin, and in the latter case, they are due to 
the noxious influence of the blood on the peripheral nerves. 
The patient thinks that he holds in his hands divers objects 
such as iron, glass, etc. These tactile hallucinations are 
generalized to the whole surface of the body. 

Among the multiple hallucinations of sight, the most 
frequent is the vision of small objects: mice, rats, beetles, etc. 
Others see horrible little spectres, hobgoblins, witches 
glaring at them. Skoda attributed these phenomena to 
scotomata. It is true that these hallucinations call to mind 
the scotoma by three definite forms. 

It is no less true that the vision of small objects is some- 
times wanting, and the patient sees instead of rats and 
mice, great troops of elephants, or bands of soldiers leap- 
ing over a wall and approaching him. Scotomata cannot 
explain this kind of hallucinations. At the same time, the 
appreciation of greatness and of volume varies even in the 
normal state ; the patient may then interpret after his own 
manner the dimensions of images due to scotoma. The 
hallucinations of delirium tremens are never stable ; they 
are almost always mobile. This phenomena finds its ex- 
planation in the fact that the poisoned blood acts continu- 
ally on the nerve centres, and keeps awake the notions of 
detail stored up in the cerebrum. The attack ends by 
a sort of agitated dream and "professional" delirium. 

Hallucinations of smell and taste are frequent; the 
patients complain of perceiving bad odors, or of their food 
having a detestable taste. The hallucinations of hearing 
are more marked than those of sight ; the patient hears 
abusive epithets reproaches, obscence' propositions, etc.; 
there are multiple voices, and every word is a menace. 

In the discussion which followed, Exner declared that 
he had been a pupil of Skoda, but did not know that the 
latter attributed to scotomata the hallucinations of delirium 
tremens. He (Exner) believed that these phenomena are 
referable to unequal and abnormal excitations of the retina 
by vitiated blood. 

With regard to the therapeutics of delirium tremens, 
(which we believe was not touched upon at the meeting 
aforesaid), it is doubtful if anything has yet been discovered 



PERISCOPE. 189 

to supersede the hypnotic and supporting treatment by 
chloral, opium, capsicum, nutrients, and occasionally, to 
meet special indications, but only for temporary effect, 
alcohol. I have been inclined to regard delirium tremens 
as a form of alcoholic paralysis, analogous to the tremble- 
ment mercurial of the French pathologists, due to saturation 
of the nerve cells of the cerebral cortex with the poison, 
and consequent enfeeblement and perversion of the sensory, 
peraptive, and motor functions. The tremulousness of the 
voluntary marches, the tongue, the members ; the vain 
attempts of the inebriate to escape his pursuing spectre, 
which generally takes on the form of vermin, reptiles, or 
the most grotesque and unnatural objects ; the haggard, 
distressful expression of the patient, who can obtain no 
sleep or rest, and whose languishing organic functions tes- 
tify to the oppression of the nervous and vital forces, all 
constitute a pathological syndrome which is peculiar to the 
disease in question. Doubtless the poison should be at 
once withdrawn, but in some cases a tapering-off method is 
certainly preferable to a sudden, complete withdrawal, 
(though such cases are comparatively few), and there are 
others where a temporary failure of the heart makes the 
exhibition of a little alcohol imperative. Sleep is undoubt- 
edly the great restorative, and to procure this recourse must 
be had to some hypnotic. I believe that experience has 
proved that chloral is much better and safer than opium. 
The combination of half a grain of morphine and twenty 
grains of chloral in violent cases is a good one. Chloral 
will sometimes be borne in very large doses. It is a good 
thing to associate with capsicum, which is a stimulant to 
the gastric expansions of the vagi nerves, and indirectly to 
the cerebro spinal centres, of great and immediate efficacy. 
Dr. Kinnear, of Portsmouth, England, used to give scruple 
boluses of powdered capsicum every two or three hours. 
Patients in less than an hour after swallowing the bolus, 
would fall into a quiet sleep, from which in three or four 
hours they would awake "calm, conscious and conva- 
lescent." 

I have given capsicum in connection with chloral in the 
form of the tincture, the dose being twenty drops. Its 
sustaining influence on the nervous centres seems to be 
marked, and it tends to counteract any depressant effect of 
chloral on the heart. 

According to Dujardin Beaumetz, (see his book " Xew 
Medications,'' translated by me, page 263), paraldehyde is a 
better hypnotic in delirium tremens than chloral. The 



1 90 PERISCOPE. 

dose is a teaspoonful as often as required to produce sleep. 

Urethan has appeared to me too feeble a hypnotic to be 
of any utility in delirium tremens, and I believe that the 
same remark is applicable to sulphonal and somnal. 

As for nutrients, milk, meat broths, the meat extracts, 
and other of the protein preparations in the market, are all 
indicated in such quantities as the generally inflamed stom- 
ach of the inebriate will tolerate. Desiccated blood (P., D. 
& Co., Detroit), is a useful alimentary food product when a 
powerful and easily assimilated nutrient is demanded. 

Lately a new treatment of delirium tremens by large 
doses oi strychnine has been recommended. To Laton, of 
Rheims, we are indebted for this therapeutic novelty. 
Laton advised doses of five milligrammes (one twelfth of a 
grain) by hypodermic injection, or by mouth ; these doses 
to be repeated twice or three times a day. Dujardin Beau- 
metz has repeated the hospital experiments of Laton with 
uniformly good success. By experiments on animals, Beau- 
metz has found "that there exists within certain limits a 
real antagonism between the action of alcohol and strych- 
nine." Drs. Journet and Bounard also report favorable re- 
sults from a series of trials in private practice of this reme- 
dy in delirium tremens, and in a number of the Bulletin 
General de TJierapeutique for 1888, appears an article by a 
Brazilian physician, Ramos, "On the employment of strych- 
nine in delirium tremens," in which he extols the effects of 
this remedy. He declares strychnine superior to all other 
remedies, morphine, chloral, paraldehyde, etc., in controll- 
ing the disordered manifestations of alcoholism. Strych- 
nine, in his belief, "has in these cases, a substitutive action 
on the nerve centres, thus antagonizing the excital action 
of the alcohol." Ramos would give large doses, hypo- 
dermic injections of one-twelth of a grain, repeated every 
four or five hours, till the insomnia, agitation and delirium 
are mitigated or disappear. In some cases, he does not 
hesitate to push the remedy till as much as a grain is given 
in the twenty-four hours. E. P. H. 

THE ELECTRICAL RESISTANCE OF THE HUMAN BODY. 

(" Rivista Sperimen'tale di Freniatria e di Medicina 
Legale," vol. xv., fasc. ii.-iii., 1889, p. 226. Observations 
by Dr. B. Silva and B. Pescarolo.) 

The following are the conclusions given by these authors, 
after a long and able article on this subject : 

1. The electrical resistance of the human body to the 



PERISCOPE. I g \ 

galvanic current, great in the beginning, descends at first 
rapidly and then more slowly, to maintain, after a variable 
time in different individuals and in the various diseases, a 
constant minimum for a given electro-motor force. The 
same facts are observed in the cadaver. 

2. The electrical resistance of the human body dimin- 
ishes with the augmentation of the electro-motor force and 
of the surface of the electrode, and vice versa, and is 
scarcely influenced by the pressure and the temperature of 
the electrode, a very little by the temperature of the body, 
increasing or decreasing with the temperature of it. 

3. The interruption has no noteworthy influence on the 
electrical resistance. Commutation has a greater influence, 
especially when the surfaces of the two electrodes are very 
different, since the resistance diminishes, especially at the 
anode. 

4. The electrical resistance of the various parts of the 
body varies with the thickness of the epidermis, and is in 
relation with the number of sweat and sebaceous glands. 
Where these are in great numbers, and where the skin is 
thicker, the resistance is greater, and vice versa. The man- 
ner of the behavior of the resistance to the palm of the 
hand and to the plantar surface of the foot is different from 
that in other regions ; there, in fact, the resistance is great 
and relatively constant. 

5. In fevers, in the exanthemata proper, in correspond- 
ence with the greater eruption, in the obese, in the dia- 
betic, in the convalescent from infectious diseases, and in 
persons with a dry skin, — the electrical resistance is great ; 
on the contrary, it is less, and it advances rapidly to the 
constant minimum, in the active person with a vigorous 
cutaneous circulation with much sweating ; as also in Base- 
dow's disease. 

6. In hysteria the increase of resistance referred to by 
Vigouroux is not constant; also the difference of the resist- 
ance from the two parts of the body in hemiplegia and hemi- 
anaesthesia, organic as well as functional, does not always 
act equally. An influence of the variation of the endo- 
cranial pressure on electrical resistance cannot be admitted, 
and pleuritic effusions make no difference. However, in 
ascites the resistance of the walls of the abdomen diminishes 
after the development of the ascitic fluid. 

7. With the antipyretics, should the temperature be lower 
ed or not, with sweating or no sweating, in the feverish as 
in the healthy, we have a diminution of electrical resistance. 
Bathing diminishes the electrical resistance of the feverish 



T g 2 PERISCOPE. 

alone when it diminishes the temperature. It has no evi- 
dent influence on the healthy. Pilocarpine, whether it pro- 
duces sweating or not, reduces the electrical tension of the 
body for the galvanic current. Penciling with oil of mus- 
tard has the same effect, as has also application of spray of 
chloroform, but in a less degree than the former. Venereal 
abuse, tobacco, emotion, fasting for twenty-four hours, the 
atmospheric state, abuse of alcohol, atropine, nitrite of 
amyl, faradization of the skin, have no manifest effect upon 
the action of electrical resistance. 

8. The particular method of behavior of the resistance 
of the human body after the galvanic current depends upon 
the modification which it induces in the epidermis, from its 
anatomical state, which also is influenced besides, as by 
external agents (traumatic causes, pressure, etc.), by the 
manner of action of the vaso-motor system, and by the 
action of various remedies. Hence it is not true that the 
measure of the electrical resistance serves to represent the 
state of the vaso-motor system ; neither has importance in 
Basedow's disease, in hysteria, in endocranial affections, 
etc., being a phenomenon wholly physical and depending 
on the vaso-motor system only secondarily. 

9. The better method of making an electrical diagnosis 
consists in using the table of Erb, with rheostat in the sec- 
ondary circuit, the electrode of equal surface (10 cm.), wet 
freely with water at 40 C, with the fixed electrode in the 
palm of the hand or in the sole of the foot, proceeding with 
the greatest rapidity possible. The best electrodes are 
made of brass or zinc with a layer of mud on its surface held 
in place by a piece of cloth or leather. They should be 
applied with a moderate pressure, and possibly always 
equal, to the skin during the electro-diagnostic examina- 
tion. 

The translator would add that this extremely interesting 
communication, instituting as it does a line of investigation 
which should be pushed much farther, should be read in 
extenso. The experimentations and observations, which 
precede and elaborate the ideas given in the conclu- 
sions which have been translated, are worthy of careful 
attention. G. P. 



THE MUSICAL SENSE IN IDIOTS. 

The Annales Medico-Psychologiques, January, 1890, 
contains some interesting references to this subject. Es- 
quirol called attention to the fact that even idiots without 






PERISCOPE. 



»93 



the power of speech could sing. Their musical capacity 
has recently been tested by Dr. Wildermuth, of Stetten. 
Children to the number of one hundred and eighty, idiotic 
in various degrees, have been examined and compared 
with eighty normal children, in regard to vocal range, the 
sense of harmony, and memory for melody. Arranging 
them in four distinct classes, beginning with those who are 
musical in the highest degree, the following results and 
proportions have been obtained : 





i st Class. 


2d Class. 


3d Class. 


4th Class 


Idiots. - - - - 


27-100 


36-100 


26-100 


II-IOO 


Normal children. - 


60-100 


26-100 


II-IOO 


2-100 



This remarkable relative development of the musical 
sense in idiots is the more striking on account of the utter 
absence of any other evidence of artistic taste. A beautiful 
landscape or a lovely picture is powerless to move them. 
At three months normal children will often manifest great 
delight at the sound of music, and retain the memory of 
melodies as early as the first year. The musical sentiment 
undoubtedly exists among certain of the mammalia (dol- 
phin, seal, mouse, ape [L. F. B.]) 

The practical outcome of Wildermuth's observations is 
to impress anew upon the medical mind the necessity, in its 
training of idiots, of vocal culture, especially the art of sing- 
ing that is accompanied by rhythmic movements. 

In a consideration of " Electricity in Mental Disease," 
referred to in the same journal, Morel finds that in simple 
melancholia and in melancholia attonita, electricity brings 
about the happiest results. In mania, electrotherapy has 
the narrowest possible field. Hallucinations of hearing are 
greatly relieved in cases of partial delirium. Dementia 
and general paresis are not benefitted. In one case out of 
nine of general paresis not lasting longer than three months, 
Heyden obtained good results from the use of electricity in 
regard to various sensations, though the mental state re- 
mained the same. Electricity renders important service in 
functional insanity such as that accompanying epilepsy, 
hysteria, chorea, and hypochondria. 

(Ibid.) Dr. E. Regis has recently called attention to the 
immense progress made in the care and treatment of the in- 
sane, during the past hundred years. While much has been 
done, there yet remains much to be accomplished. " It is 
not sufficient," say Regis, of Bordeaux, " to point with pride 



I Q4 PERISCOPE. 

to the road already travelled, and applaud the excellence 
of our predecessors. The world moves, it must move. We 
have something to do in this matter ourselves, a duty to 
perform. Everything can be made more perfect ; and how- 
ever obscure each one of us, we must all work earnestly at 
a task at once difficult yet full of consolation ; the progres- 
sive, constant amelioration of the condition of the insane." 

EPILEPTIC ARITHOMANIA. 

(Ibid.) Under this title, Dr. A. Cullere, records several 
cases of epileptics who have a mania for counting, for com- 
bining numbers of all kinds, particularly calculations in re- 
gard to divisions of time, such as seconds, minutes, hours, 
days, months, years, and centuries. In one instance, a 
young man of twenty-seven, and a victim of epilepsy, cried 
out suddenly to the doctor, in the midst of an attack of 
acute mania, in which he imagined himself surrounded by 
brigands and assassins : " Shall I tell you how many min- 
utes there are in one hundred thousand years ? " This was 
an evidence of a temporary return to his abnormal normal- 
ity, to the individual inherent departure from normal men- 
tality that constituted his natural state. Professional math- 
ematicians and some few children are the only persons who 
find real pleasure in arithmetical calculation. Possibly the 
epileptic arithomaniacs resemble such children. With the 
unfortunates under consideration, this mania for calculations 
differs materially from similar mania in those of inherited 
mental instability. The latter are pained and fatigued by 
arithmetical calculation even to the point of anguish, and of 
well-defined melancholia. Not so the epileptic. Calcula- 
tion is an amusement. Even fractions are a source of 
pleasure. The mysticism of epileptics, their irascibility, 
their changeable moods, expansive religiousness, sexual 
aberrations, and alcoholic excesses, are due to inherent 
mental qualities, as is arithomania, and not to any special 
hereditary unsoundness of mind. 

POST-FEBRILE INSANITY. 

In the Johns Hopkins Hospital Reports, No. I, Vol. ii., 
seven cases of post-febrile insanity are cited. The prog- 
nosis is always good, recovery usually taking place within 
three months. The patient should be cared for at home 
whenever possible. Seclusion, incessant watchfulness, 
absolute rest in bed, with massage and careful feeding, 
constitute the essentials in treatment. 



PERISCOPE. 195 

CHLORALAMID. 

According to the Glascow Medical Journal, Dr. 
Peterson (Lancet, October 26, 1889,) has tested this drug 
in fourteen cases of insomnia. There were four cases 
of simple sleeplessness, two being over sixty years of 
age. The results were most satisfactory, as they were in 
three cases of phthisis with profuse night sweats. The 
night sweats were checked in marked degree. In two 
cases of heart disease, doses of thirty grains gave fair rest, 
eased pain and relieved cough. Restlessness resulting from 
pain was but slightly benefited. The undesirable effects 
were giddiness, feeling of sickness, dryness of the mouth, 
and even slight delirium. Its action is not so rapid as 
that of chloral, sleep ensuing only in a half hour or an hour. 
The doses recommended are from thirty to forty-five grains 
for a man. and twenty to thirty grains for a woman. The 
absence of any depressing effect on the circulation makes it 
an invaluable agent in cases where there is any cardiac 
affection. This drug is also referred to by Dr. Leech, in the 
discussion on " Recently Introduced Hypnotics and Anal- 
gesias," in the last annual meeting of the British Medical 
Association. It is adapted to the sleeplessness of nervous 
people and those suffering from spinal disease, bronchial 
asthma, subacute rheumatism, and gastric disorders, un- 
associated with great pain. Dr. W. Hale White (British 
Medical Journal, December 14, 1889), has given chloralamid 
in twenty cases in which insomnia was a prominent symp- 
tom, with thoroughly satisfactory results with but two ex- 
ceptions. Some of the patients were suffering from ex- 
tremely painful diseases, yet the drug produced sleep, 
sometimes acting better than morphia. Its success was 
undoubted in cases of enteric fever, malignant disease, 
aneurism, nephritis, cardiac disease, ascites, erysipelas, 
rheumatic fever, eczema, phthisis, brachial monoplegia, and 
spastic paraplegia. 

ASTHMA AS A NEUROSES. 

The Medical News of Jan. 4, 1890, contains a suggestive 
paper with this title, by J. G. Carpenter. The author thinks 
that rheumatism and gout play an important role in asthma; 
and during sudden changes of weather or temperature, 
asthma, bronchitis, or some skin eruption may appear in 
the absence of a rheumatic or gouty attack. U'raemia, 
from diseases of the kidneys, may cause the most severe 
attacks of asthma. That this disease, so much more preva- 



1 96 PERISCOPE. 

lent in childhood, is due, the author thinks, to improper 
management of the child at birth. Even within a half 
hour after its advent into this cold world, a rhinitis may 
be developed from undue exposure and the rapid evapo- 
ration from the body and the radiation of heat. The child 
starts in life with a cold, has continued recurrences, there- 
by establishing chronic or subacute catarrhal inflamma- 
tion of the upper air passages, which its sequlae furnishes 
the most potent pre-disposition to asthma. Prognosis is 
good, if proper treatment is given before irreparable struct- 
ural lesions have taken place. Asthma depends on three 
conditions: 1. Neurotic habit, as shown by Salter. 2. Dis- 
eases of other nasal mucous membrane. 3. Obscure con- 
ditions of the atmosphere. To Dr. Loomis the profession 
is indebted for the use of morphine as an antidote to urae- 
mic poisoning. In complete coma, one-half to one grain 
injections have been given by him. He claims positive 
relief of distressing symptoms, and in addition: 1. to arrest 
muscular spasm by counteracting the effects of the uraemic 
poison on the nerve centres ; 2. to establish free diaphoresis; 
3. to facilitate the action of cathartics and diuretics, more 
especially the diuretic action of digitalis. In renal asthma 
morphine is a therapeutic remedy of the highest value. 
The writer believes it has a special effect — also belladonna — 
on the speno-palatine ganglion. 

The speno-palatine ganglion supplies branches to the 
nose, throat, soft palate, and Eustachian tube. It possesses 
a sensory, motor, and sympathetic root ; and is connected 
with the pneumo-gastric and facial nerves, and through its 
numerous connections an intimate sympathetic relation is 
established between the throat, nose, ear, larynx, trachea, 
and bronchial tubes. Removal of this ganglion causes a 
severe catarrhal condition of the nasal mucous membrane. 
This membrane is continuous with that which lines the eye- 
lids and nasal duct, the throat, Eustachian tubes, the middle 
ear, larynx, trachea, and bronchial tubes. An irritation or 
congestion started in the nasal chambers may extend re- 
flexly to the preumo-gastric nerve, and cause asthma by 
bronchial spasm ; or the irritation may be so great as to 
cause, in addition to asthma, acute or subacute catarrhal 
inflammation of the upper air passages and bronchial tubes. 
Opium and its preparations and belladonna have a specific 
effect in allaying irritation and checking inflammation and 
secretion in the npper air-passages by acting on the nerve 
centres, and are highly important not only during parox- 
ysms of asthma, but in the intervals to assist local treat- 
ment in allaying chronic irritations and congestions. In 



PERISCOPE. I 9 7 

connection with quinine and nux vomica, they exert a 
powerful tonic influence on the vaso-motor nervous system. 
In tonic doses thrice daily, they prevent the return of asth- 
ma while the intra-nasal disease is being cured locally. 
Nitroglycerine has an important place during the paroxysm 
and in the intervals of respite. Chloral hydrate allays the 
attacks. When the paroxysms are violent and threaten 
life, chloroform is of great use. L. F. B. 

DIPSOMANIA. 
T. S. Clouston, M.D., F.R.C.P.E., in the "Edinburgh 
Medical Journal," for February, 1890, continues his com- 
munications on the subject of " Diseased Cravings and 
Paralyzed Control," by treating of dipsomania, which he 
attempts to define. He first refuses to apply that name to 
those forms of mental disease in which an intense craving 
for alcoholic drink is merely a prominent symptom, and 
deplores the careless use of that term by practitioners who 
apply it to such states and employ it inaccurately. Thus 
cases of simple coherent mania — that is, with distinct men- 
tal exaltation, insomnia, restlessness, talkativeness, changed 
habits, loss of common sense, morbid brilliancy of imagina- 
tion, and hyperaesthetic memory — must not be called cases 
of dipsomania, though such patients may drink excessively, 
have all their symptoms aggravated by it, and have an 
intense craving to get it. He also cited a case of folie 
circalaire, in which the phase of exaltation always began 
after abuse of ardent spirits, which he craved and obtained 
at all hazards as long as it was possible to do so ; yet this 
was not true dipsomania. 

In simple melancholia, in epilepsy, in many cases of 
mild dementia, there are often manifested quite uncontrol- 
lable longings for drink, as also in some cases of delusional 
insanity, paranoia, and general paresis, and even in rarer 
cases of softening of the brain, tumors, cerebral syphilis, in 
which a craving for alcohol was one of the earlier symptoms. 
Drink-craving with loss of control is sometimes one of the 
early signs of the break-down of senility. But a dipso- 
maniac, while he remains a pure case of that disease, has no 
systematized delusions, no amnesia, and no motor symp- 
toms, and has seldom strong suicidal or homicidal impulses. 
The greatest difficulty in the diagnosis of dipsomania is to 
distinguish it from drunkenness, in which, however, the 
control is not paralyzed, but simply not exercised; whereas, 
in true dipsomania, the power of control is abolished. It is 
therefore a form of diseased craving or impulse, with para- 
lyzed — wholly or partially — inhibition, and may be divided 
into four classes : 



[ ng PERISCOPE. 

1. Developmental and reti'ogressive dipsomania, which 
includes the congenital cases, whose higher inhibition had 
never been developed as a brain-faculty. 

2. Dipsomania of a neurotic diathesis, comprising those 
cases having high brain qualities, or keen sensibilities and 
poetic minds, or of hyperaesthetic conscientiousness, but 
who are carried away by the force and intensity of their 
emotions, and lose control over their cravings. 

?. Somatic dipsomania, or cases in which traumatism, 
sunstroke, paralysis, cephalic erysipelas, cerebral lesions of 
all sorts, so weaken the self-control that men, who had 
previously led sober lives, then acquire marked and uncon- 
trollable cravings for liquors. 

4.. Dipsomania of excess includes those forms in which 
there is no especial heredity, no neurotic diathesis, no dis- 
ease, and no critical period of life, and where there has 
previously been a prolonged and excessive use of stimu- 
lants. 

In regard to treatment, he recommends " legal control" 
for many cases — i. e., enforced abstinence in an asylum, 
total abstinence in free individuals, special asylums for those 
willing to be treated there, the employment of every means 
to strengthen the bodily health, the judicious use of special 
expedients (drugs), and, as a means of prophylaxis, the 
correction and development of the weak points in the 
children of the first division. 

TREATMENT OF DIPSOMANIA BY HYPNOTISM. 

Dr. Hayes, secretary of the London Hypnotic Society, 
comes forward with another statement in favor of the em- 
ployment of hypnotism in dipsomania. The previous publi- 
cations on the subject by Ladame, Forel, and others are 
also in support of the belief that long periods of abstinence 
and even permanent cures are obtainable by this method. 
While the idea of curing dipsomania by hypnotism and 
suggestion is not a very new one. yet it is well to call the 
attention of the medical profession to it, in order that it 
may be more widely known and practised. The patient 
submits to hypnotism two or three times a week, and, when 
he is in the proper condition, the hypnotist suggests to his 
now pliant and receptive mind that he will have no desire 
for drink on awaking and that he will even have a repug- 
nance for it. After several seances of this nature the desire 
diminishes, ceases altogether, and the patient loses the 
habit of drinking alcoholic beverages. Relapses often 
occur, it is true, but, on the other hand, cures are often 
permanent. — Quarterly Journal of Inebriety, January, 1890. 



PERISCOPE. 



99 



EXPERIMENTS RELATING TO THE ACTION OF ALCOHOL 
ON THE BRAIN. 

Dr. J. J. Ridge, physician to the London Temperance 
Hospital, publishes the results of his experiments in the 
" Medical Temperance Journal." He admits that alcohol 
acts as a narcotic, thereby dulling the action of the cortical 
centres. His experiments, which required a considerable 
degree of mental as well as muscular alertness, consisted in 
the endeavor " to pass a pointed stick through a swinging 
ring, counting the number of swings between each success- 
ful endeavor, and adding these together when sixty had 
been accomplished. A certain dose of rectified spirit was 
then taken, and after fifteen minutes the number of swings 
required to accomplish sixty more successes was counted." 

The following table shows the results of his experi- 
ments : 



Alcohol. 



1 drachm 


i 




! 


2 drachms 




3 drachms 


1 

i 


-1 drachms 





Xo. of Sitings 


.To 


of Strings 


age of 


before. 






offer. 


Increase. 


153 






169 


10.5 


113 






12n 


11.6 


112 






123 




166 






194 


16.9 


145 






156 


7. n 


132 






154 


16.6 


125 






146 


. - 


134 






185 


- 


115 






142 


23 5 



44.6 



It is thus seen that, after the ingestion of the alcohol, he 
was less successful in passing the stick through the ring 
than before taking that agent, and it is also seen that the 
degree of insuccess was approximately proportional to the 
quantity of alcohol absorbed. Each experiment was done 
on a different day, so that no influence upon the results can 
be attributed to fatigue. The several functions of the brain 
and spinal cord that are tested in these experiments are : 
ist, the steadiness of the hand (co-ordination of muscles) ; 
2d, visual acuity ; 3d, accuracy of judgment; 4th, rapidity 
of thought (perception and decision) ; 5th, rapidity of mus- 
cular action ; 6th, power of self-control. 

The experiments of Kraepelin, published by Lander 
Brunton, in his text-book of pharmacology, point in the 
same direction. This experimenter studied the influence of 



200 PERISCOPE. 

alcohol in three forms of tests, viz. : (a) to find the time 
required for simple reaction, i. <?,, for a message received by 
the senses and returned by the motor nerves ; (/>) for dis- 
crimination ; {c) for decision. In all of these tests, involving 
a certain interposition of cortical activity, the mental pro- 
cesses were found to be prolonged and retarded by the 
absorption of alcohol by the person under experiment. 

DRUNKENNESS : ITS INFLUENCE UPON THE MIND. 

Dr. T. L. Wright, of Bellefontaine, Ohio, has an article 
in the " Quarterly Journal of Inebriety," for January, in 
which he studies the effects of alcohol upon the mind. He 
rightly disparages the common opinion that this substance 
really adds to the power, scope, and brilliancy of intellectual 
operations, and truly remarks that the poison impresses and 
modifies the mental faculties separately and in detail, and 
also throws an undefined and immovable glamour over the 
mind as a whole, so that it is quite incapable of correctly 
judging of its own condition. The attention of an intoxicated 
man is more difficult to enlist than that of a sober man, 
because, his nervous sensibilities being enfeebled, he is not 
thoroughly alive to ordinary sensations and impressions, 
and for this reason his ideas become fixed, his opinions 
unchangeable, while in this state. He may not even rightly 
feel the flight of time, and be astonished when told how late 
it is. Under the same circumstances wonderful egotism 
becomes developed in him. The geniality and good-nature 
of new intoxication are intensely selfish. He loses his 
affection, love, or regard for others, and manifests a morbid 
feeling of grandeur united with one of condescension for 
others. When used as a stimulant by public speakers, 
alcohol is apt to cause a superficial fluency of speech, while 
really detracting from its merit or wit. It causes the 
expression of empty assumptions and baseless exaggera- 
tions, and the delivery of a string of pompous or high- 
sounding verbiage, instead of words pregnant with thought. 
It also produces a diminution of sensations and a dullness 
of perception, and often an aberration of the latter, so that 
illusions, hallucinations, and delusions are produced. The 
idea that somehow he is physically invulnerable is no doubt 
largely due to the dullness of sensation and perception in 
the person intoxicated, and this idea is no doubt the cause 
of those rash exhibitions of reckless courage often given by 
intoxicated persons. 

The influence of alcohol upon consciousness is well known. 
All the mental processes included under that term are im- 
paired by it. Memory, judgment, discrimination, are para- 



PERISCOPE. 20 1 

lyzed by alcoholic anaesthesia. Reasoning is impossible, 
for the "data of consciousness" are dim, imperfect, or 
absent. 

The author concludes by observing that alcohol in small 
quantities will render consciousness dim, feeble, unreliable, 
while in larger portions it will disorganize the powers of 
consciousness, or will totally wreck and destroy it. 

OX THE DIAGNOSIS OF NEURALGIA IN AND ABOUT 
THE EVES. 

Dr. A. D. Williams calls attention to a symptom attend- 
ing neuralgia of the fifth pair, which he justly considers 
quite important, viz.: the tenderness of the skin after the 
attack has passed off, or even while the pain is present. 
Touching of the scalp or slight pulling of the hair is pain- 
ful. The eyeball may also be tender to the touch. Other 
aids to diagnosis are the frequent periodicity of neuralgia, 
and the fact that if any considerable inflammation is present 
the pain is probably not neuralgic. — St. Louis Med. and 
Surg. Journal, Feb., 1890, p. 109. 

IODOFORM IN CEREBRO-SPINAL MENINGITIS. 

"In the Tchernigov weekly ' Zemsky Vratch,' No. 10, 
1889, p. 151, Dr. G. Levitsky, of Vostrovskaia, calls atten- 
tion to excellent effects in cerebro-spinal meningitis ob- 
tained from the internal administration of iodoform given 
in the form of two-grain pills, three times a day. He 
reports a striking case, that of a woman suffering with an 
exceedingly severe form of the disease, in which, after all 
other means had utterly failed, the administration of the 
drug was almost immediately followed by a steady im- 
provement. On the third day of the treatment contractures 
of the right, and on the fifth of the left, upper limb dis- 
appeared ; by the end of the fourth week the patient was 
practically well The drug was therefore discontinued. 
A relapse, however, rapidly followed, but yielded at once 
to another course of iodoform ; a complete and permanent 
recovery taking place ultimately. In all, one ounce of iodo- 
form was taken in the course of two months. Xo untoward 
accessory effects were ever observed." — Canada Med. Record, 
Jan., 1890. 

THE BROMIDES IN EPILEPSY. 

"Dr. Moritz Gauster, whose extensive experience in the 
treatment of this disease enables him to speak authorita- 
tively, concludes as follows: (1) The bromide treatment in 



202 PERISCOPE. 

epilepsy is the most successful, particularly in idiopathic 
cases. (2) As a rule, the bromides must be administered 
for years, the dose in each individual case being regulated 
by observation. (3) By careful observation of the condition 
of patients, as much as 20 grammes can be given daily 
without manifest injury. (4) The bromides must be sus- 
pended or supplanted by other agents, (a) When digestive 
disturbances supervene ; when slight they are of no con- 
sequence, and generally disappear, notwithstanding their 
continued use ; (6) when catarrh of the pulmonary apices 
can be detected ; (c) when ulceration of the skin or any 
cutaneous complication exists. (5) Involvement of the 
intelligence does not indicate a discontinuance of the bro- 
mides. (6) Pulmonary tuberculosis, severe cutaneous lesions 
and grave nutritive disturbances alone forbid the bromide 
therapy. When combating the attacks of epilepsy this is 
not of such vital importance as preventing the supervention 
of severe psychoses. (7) Emaciation is no contraindica- 
tion, as the weight may increase when sufficient nutritive 
elements are ingested. (8) During the treatment attention 
must be directed to the nutrition, and at intervals to the 
lungs and skin. — Wiener Medizen Presse. From Canada 
Med. Record, Jan., 1890. 

THE DISPOSITION TO BE MADE OF CRIMINAL LUNATICS. 

Dr. W. W. Godding, superintendent of the Government 
Hospital for the Insane at Washington, discusses the three 
methods of disposing of insane criminals, viz.: Retention 
in an asylum, hanging, and release. The last method can 
not, of course, be put into practice, as the safety of the 
public requires that the homicidal maniac be deprived of 
his liberty. The second method is certainly sure and 
radical, admitting of no revision, and freeing the community 
from a dangerous individual. This method of treatment by 
hemp is evidently the simplest of all, yet it does not accord 
with our present views of sociology. The author naturally 
concludes in favor of the first-named method, and also adds 
another plea for the rational and humane treatment of 
insane criminals, which consists in their removal from the 
ordinary hospital for the insane to a special department of 
an asylum, or State hospital for the insane, where the)- will 
be cared for in a suitable manner. He closes with a 
description of Howard Hall, a building attached to the 
Government Hospital at Washington, in which the criminal 
insane are thus disposed of. — Medico-Legal Journal, \^zc-, 
1889. 



PERISCOPE. 203 

SYMPTOMS OF GRAVE DISEASES OF THE NERVOUS SYSTEM 
RELIEVED BY RESTORATION OF THE EQUILIBRIUM 

OF THE MUSCLES OF THE EYE. 
Dr. J. F. Fulton, professor of ophthalmology and otology 
in the University of Minnesota, recounts his successes in 
this direction. In 260 cases of heterophoria in which he 
operated, cephalalgia was present in 190 cases. In the vast 
majority of these cases the headache was cured ; in nearly 
all relieved. This fair degree of success prompts him to go 
to the extreme and to say, that before any case of headache 
is treated, the condition of the ocular muscles should first 
be tested. In three cases which he terms chorea of the 
lids and face in children between ten and twelve years of 
age, the symptoms were completely relieved by a partial 
tenotomy of some one of the recti with correction of the 
abnormal refraction. He has had no experience with epi- 
lepsy. Neurasthenia in a business man of forty, who had 
vainly consulted the celebrities in neurology of the metrop- 
olis of four countries in both hemispheres, yielded to his 
magic touch. Even cases of hemianesthesia, with partial 
unconsciousness, vertigo, complete aphasia, diplopia, and 
hemiopia, causing the physician in charge to fear the exist- 
ence of some cerebral lesion, were cured by a few snips of 
the scissors, of a stroke or two of the knife. In closing, 
however, he says : My conclusions are exactly those of Dr. 
Webster, viz.: (1) Xo person should have a tenotomy per- 
formed solely because he is the subject of heterophoria. 
(2) But slight degrees should be corrected where trouble- 
some symptoms exist which may be due to the too great 
use of nervous force in co-ordinating the eyes. (3} Other 
means should be resorted to before trying tenotomy, but 
unnecessary delays should be avoided. (4) Tenotomies 
should be performed under cocaine. (5) In judiciously 
selected cases, where the operation is properly performed, 
the average results will be quite as satisfactory as the 
results of most other surgical operations. — Northwestern 
Lancet, Feb. 1, 1890. W. W. S. 

THE EFFECT OF STIMULATION ON THE POLARIZATION 

OF NERVE. 

Dr. George Stewart has made an elaborate study of the 
subject. In his first paper he determines whether stimula- 
tion has any effect on the polarization of a nerve. Her- 
mann assumed for the explanation of the apparent change 
of resistance produced in a nerve by tetanizing that the 
positive polarization during the flow of the polarizing current 



204 PERISCOPE. 

is increased bystimulation. The question then is, how is the 
polarization after current affected by stimulation? He studied 
this in two ways. In one the polarization was allowed to 
become pretty steady and then the nerve tetanized and the 
effect observed. In the other the stimulation was continued 
during the whole flow of the polarizing current and the 
amount of polarization compared with that produced by a 
similar current when the nerve was at rest. These two 
methods were used, but as a matter of fact the latter method 
is not suitable for long periods of flow as the former, 
because the prolonged tetanus exhausts the nerve. There 
is this difference between the methods, that in the first case 
the stimulus acts upon a polarization already established, 
while in the second it may be supposed to influence the 
establishment of that of polarization. His apparatus was 
arranged so that any one of the three circuits could be 
closed at will. In one of these the circuit was the nerve and 
battery, in the second the nerve and the galvanometer, and 
in the third the nerve battery and galvanometer. The sci- 
atic nerve of a frog was used, and his results were as fol- 
lows : 

I. The effect produced by stimulation is in the direction 
of diminution of the positive polarization. 2. Within limits 
the effect is somewhat greater the longer the time of flow of 
the polarizing stream. 3. The effect increases within limits 
with the density of the polarizing current. 4. As might be 
expected the effect increases with the strength of the stimu- 
lus. In his second paper he considers more in detail the 
work of his preceding paper. The object of the inquiry was 
to investigate the electrical changes which take place in a 
polarized nerve when it is stimulated both during the flow 
and after the opening of the polarizing current, so far as 
these changes have not hitherto been studied or where the 
study of them has been incomplete. He tried to obtain not 
only qualitative but also quantitative results, relying in the 
latter case rather on comparison of different experiments 
upon the same nerve than on observations made on different 
nerves at different times. 

1. Galvanometric observations during the flow of the 
polarizing current where the whole intra-polar area is led 
off to the galvanometer — I. Stimulating electrodes in extra- 
polar region — here with stimulation on the anodic side, a 
limiting intensity of current can be reached for which the 
stimulating effect disappears altogether. 

2, Stimulating electrodes in intra-polar region. When 
we come to the comparison of the extra and intra polar 
effect with intra-polar stimulation, we shall find additional 



PERISCOPE. 205 

evidence to show that the anode becomes impassable about 
the time when the intra-polar area in general has lost its 
conductivity and excitability. On the other hand, it is seen 
that long after the cathodic block has developed itself intra 
polar stimulation is effective, producing indeed somethiug 
like its maximum effect with the current density which cor- 
responds to the beginning of the block. 

II. Galvanometric observations during the flow of the 
polarizing current, when an extra polar area is led off to the 
galvanometer. 1, Stimulating electrodes extra polar. Here 
it may be said that in general even 20 after opening the 
polarizing current the after effect on the cathodic side 
is greater than the effect during the flow, while on the side 
of the anode this relation is reversed, 2. Stimulating elec- 
trodes in the intra polar region. Here the chief points of 
difference between these results and those with extra polar 
stimulation are, (1), the almost complete absence of any 
stimulation effect on the side of the cathode, except with 
the weakest currents, and (2), the absence of the positive 
effect on the anodic side. 

III. Observations during the flow of the polarizing cur- 
rent, when the whole intra-polar area is led off to the gal- 
vanometer alternately with an extra-polar area. Here the 
intra-polar effect and the extra-polar anodic effect rise and 
fall together. The maxima and minima of the two effects 
correspond closely enough. From the preceding data he 
arrives at the conclusion that the stimulative effects during 
the flow of the polarizing current cannot be explained 
entirely as secondary action currents, but are probably due 
to the super-position of such currents on electro-tonic varia- 
tions. 

IV. Observations after opening the polarizing current 
when the whole intra-polar area is led off to the galvano- 
meter. 1. Stimulating electrodes, extra-polar. Here the 
stimulative effect may fail altogether after the opening of a 
strong current if the excitation has to pass the anode, while 
if it has onlyto pass the cathode we may have a large effect, 
2. Stimulating electrodes, intra-polar. Here the direction of 
the polarizing current is without influence on the amount of 
the stimulation deflection. 

V, Observations after opening the polarizing current 
where an extra polar region is led off to the galvanometer 
1. Stimulating electrodes, extra polar. When the polarizing 
current is ascending we get a cathodic after current in the 
same direction, When the polarizing current is descending, 
the main anodic after-current in the opposite direction is 
the one which affects the galvanometer, 2, Stimulating 



206 PERISCOPE. 

electrodes, intra-polar. Here as before the sign of the effect 
is positive in the anodic area, negative in the cathodic. 

VI. Observations after opening the polarizing current 
when the intra and extra polar regions are led off alternately 
to the galvanometer, the stimulating electrodes being 
extra polar. The general result was that a large extra 
polar effect was associated with a small intra-polar effect. 

VII. Observations after opening the polarizing current 
when a part of the intra-polar area is led off to the galvano- 
meter. 

(i.) Stimulating electrodes, extra-polar. When the exci- 
tation has to pass the cathode the effect diminishes, when 
any considerable portion of the intra-polar area lies between 
it and the led off part and it disappears ultimately. 

(2.) Stimulating electrodes, intra-polar. Here in general, 
when the anode is in the led off area, the effect is the 
greatest. 

VIII. Observations after opening the polarizing current 
when the whole intra-polar region and part of it or two 
different parts of it are led off successively to the galvano- 
meter, the stimulating electrodes being extra-polar. The 
results are that except with the strongest currents the effect 
is greater when the galvanometer is connected with the 
anode than when it is connected with the cathode. 

IX. Experiments on muscular contraction, with intra- 
polar stimulation. 

(1.) During the flow of the polarizing current. 

Up to a certain strength of current a stimulus will give 
contraction when the cathode lies next to the muscle, which 
will give no contraction when the anode is in that position. 
Above this strength the reverse holds good and a stimulus 
which is followed by contraction when the excitation has to 
pass the anode, evokes no response when it has to pass the 
cathode. 

(2.) After opening the polarizing current his results were 
as follows : 

1. With a very short time of closure, a. — If we adjust the 
stimulus so that contraction shall occur immediately on 
opening the descending current there will be no contraction 
for some time after opening the ascending current. ^.=If 
we adjust the stimulus so that contraction shall not occur 
for some time after opening the descending current it will 
take a longer time to appear after the ascending current. 

2. If we determine the strength of the stimulus which is 
just necessary to give contraction immediately after open- 
ing, it will come out greater for the ascending than for the 
descending current. 



PERISCOPE. 207 

3. When an interval has existed during which the stimu- 
lus has been inoperative, the contraction does not reach its 
original height for some time after the stimulus has again 
become effective, and this time is longer after the ascend- 
ing than after the descending current. He does not see how 
the conclusion can be avoided that after opening the polar- 
izing current a rapid, perhaps instantaneous reversal of the 
relations of the poles takes place. 

The remainder of the paper is devoted to a discussion of 
preceding facts in regard to conductivity and excitability. 
He states, " I do not now say that excitability and conduc- 
tivity are separable properties. What I say is that we 
know nothing in the manner of propagation of a nerve 
impulse which goes against such a supposition. We know 
much which supports it." — The Journal of Physiology, vol. 
i<., No. 1, 1888 ; and vol. x., No. 6, 1889. Isaac Ott. 

EXCEBPTS FBOM ITALIAN JOURNALS. 

By ALBERT PICK and F. H. PRITCIIARD, M.D., Boston. 
ON" TWO CASES OF RUMINATION IN THE INSANE. 

Dr. G. B. Verga (Archivo Italiano per le malattie ner- 
vose, 1886, xx vi., p. 149). The writer, after giving a review 
of the relatively rich literature on rumination in man, com- 
municating at the same time two cases of his own with 
post-mortem results, turns to the explanation of this phe- 
nomenon. That it is not a disease which most writers 
admit is seen from the most various pathological results 
found in patients with this symptom, as well as a perfectly 
normal condition of the organs of deglution and digestion ; 
especially does he object to those writers, who, like Canta- 
naro, would have it regarded as an atavistic sign. Even 
Cantaro had to confess that Very many of his 69 cases from 
literature, of which only 36 were mentally abnormal, had 
not ruminated from childhood ; hence it was to be regarded 
as an acquired peculiarity — according to the writer, as a 
bad habit. Thus it is chiefly found in avoracious individ- 
uals, for example, in imbeciles, then in people who have no 
time to eat, and especially in children, in business men, 
learned men, etc., and finally in persons with faulty appa- 
ratus of mastication. 

Hence, one should, strike merycisus from the list of 
degenerative and atavistic phenomena. 

SURGICAL OPERATIONS AS A CAUSE OF INSANITY. 

Dr. R. Gucci (Rivista sperimentale di Freniatria, 1889, 
xv., p. 50). The writer, in his excellent treatise on surgical 
operations as a cause of mental disturbances, first excludes 



208 PERISCOPE. 

all those cases where there was a cerebral concussion as a 
cause of origin of psychoses, and from his careful study of 
the literature and from observations : 

i. Ovariotomy in a seventy-four -year woman, with 
mania during convalescence, three months after the opera- 
tion. 

2. Ovariotomy in a thirty-one-year-old woman, with at- 
tacks of violent excitement ten days after operation, which 
returned and led to imbecility. 

3. Ovariotomy in a forty-two-year-old woman, who had 
an insane attack in the twenty-fourth year, and then for 
sixteen years remained completely well, and only "four 
weeks after the operation was she attacked anew. 

4. Enucleation of the eyeball in a sixty-year-old woman, 
with immediately following grave melancholia. 

He comes to the conclusion that in rare and exceptional 
cases an operation may be the cause of origin of a psychosis. 
Contrary to the rarity of its appearance, he does not think 
it a contra-indication in individuals predisposed for an 
operation which otherwise would have to be performed. 

Psychoses seems most frequently to follow operations on 
organs which have an intimate nervous connection with the 
central nervous system, as the sexual organs and those of 
sense. 

Further, the fever, the loss of blood, and especially the 
chloroform narcosis, may have a certain influence. 

CHOREA HEREDITARIA (HUNTINGTON'S CHOREA). 
CHRONIC PROGRESSIVE CHOREA. 

Dr. G. Leppilli (Revist. sperimental. di Freniatr. etc., 
1888, xiii., p. 453) gives a record of the cases of the disease 
known up to date, and forms a clinical picture of this rare 
disease, essentially distinguishing itself by its constant 
transmission by heredity, often through many generations 
and then making an outbreak later on, generally between 
the thirtieth and fortieth years, and by its gradually pro- 
gressive functional disturbance of always new groups of 
muscles (even of the tongue), and by its incurability from 
the usual chorea. The abnormal movements are aggra- 
vated by emotions, while they, contrary to the usual form 
of chorea, may be more or loss completely suppressed by 
intended motions ; during sleep they cease completely. 
Disturbance of sensibility are wanting; the mechanical and 
electric irritability is unchanged, the reflexes are normal, 
exceptionally heighthened. Especially after a more or 
less duration of the disease are slight psychic disturbances 



PERISCOPE. 209 

strikingly frequent, which may even increase to melan- 
cholia with inclination to suicide. This disease, dependent 
upon a hereditary neuropsychopathic base, is not rarely 
accompanied by a general progressive dullness of the mind. 
The members of a family afflicted with this form of chorea 
who remain free are also frequently demented, or at least 
bazarre and "nervous." If one generation has been spared, 
then their posterity may be regarded as immuned. 

A MODIFICATION OF WEIGERT'S METHOD FOR THE 
COLORATION OF NERVOUS CENTRES. 

G. Vassale (Revista speriment. di Freniatr. edi medicina 
leg., etc., 1889, xv., p. 102) recommends the following modi- 
fication of Weigert's method of coloring by haematoxyline, 
where the objects are hardened in Muller's solution or in a 
kali bichromate solution and kept in alcohol. He uses three 
solutions. 

1) Haematoxyline, 1 gr. in 100 gr. of hot distilled water. 

2) A saturated and filtrated solution of cupric acetate. 

3) Borax, 2 gr. and kalibichromate, 2.5 gr. in 300 gr. of 
distilled water. 

The sections are first placed into solution 1 for three to 
five minutes, then the same time in solution 2, and after a 
rapid cleaning are thrown into solution 3, where they lose 
their color again. Then they are washed again and the 
water removed by absolute alcohol, brightened up in a 
carbo-xylol solution (1 carbolic acid, 3 xylol), and then laid 
into xylol — Canada balsam. After the color being taken 
out in solution (3), they may again be colored in alum, car- 
mine or picrocarmine. 
THE EFFECTS OF EXTIRPATION OF THE CCELIAC PLEXUS. 

A. Lustig (Turin) (Archiv. per le Scienze med., 1889, 
xiii., 6). This experimenter used dogs, and especially 
rabbits. The peritonaeum was opened and the plexus 
removed ; the technique may be read in the original. 
Eleven successful rabbit and two dog-experiments yielded 
the following : The gastro-intestinal tract showed no dis- 
turbances. A few hours after the operation a transient 
glycosuria appeared, which at the most continued two days. 
An atrophy of the pancreas never appeared. In the first 
days — sometimes with and sometimes without mellituria — 
acetonnria appeared. This often lasted until death, with 
continued decrease in the body-weight and the temperature, 
and with slowing of the respiration; death generally appears 
in a few weeks from coma acetonicum. Some of the ani- 
mals recovered. The changes in the kidneys were those 
of acetonuria. P. & P. 



Society Reports. 

NEW YORK NEUROLOGICAL SOCIETY 

Stated Meeting, Febrtiary 4, i8go. 
President, Dr. Geo. W. Jacoby, in the Chair. 
Dr. Christian A. Herter described a case of 

MULTIPLE CEREBRAL SOFTENING, WITH WIDESPREAD EN- 
DARTERITIS AND A DISSECTING ANEURISM OF A 
BRANCH OF THE LEFT MIDDLE CEREBRAL 
ARTERY. (See page 156) 

Dr. Fisher said that he had observed many cases of 
endarteritis and softening among the aged in the city alms- 
house. He described the case of a woman who was dull 
and stupid, had had two attacks of aphasia, together with 
hemiplegia, and who was syphilitic, syphilis and alcoholism 
being common to most of the almshouse inmates. In this 
patient there were undoubted occlusion of arteries and soft- 
ening. He believed it would be impossible to distinguish 
between syphilitic and atheromatous disease of the vessels. 
He had noted as quite characteristic of specific cerebral 
endarteritis extreme dullness and stupidity. Often the 
pupils were irregular and sluggish in their reaction to light. 
He would consider the hebetude in Dr. Herter's case as 
due to the general condition of the vessels rather than to 
the lesion in the frontal lobe. 

Dr. Starr asked the reason of the asymmetry of the 
hemispheres presented in the drawings. 

Dr. Herter said that oedema of the left side was the 
cause of the disproportion. In reply to Dr. Fisher he 
stated that his case was not syphilitic and the age was but 
32. Naturally softening was common in people of ad- 
vanced age. 

Dr. FRANK H. Ingram then read a paper entitled 
A CONTRIBUTION TO 1HE STUDY OF EPILEPSY. (Seepagel65) 

Dr. Starr thought it interesting to hear of the apparent 
relation existing between changes of barometric pressure 
and the frequency of epileptic attacks. There was nothing 
which tended to produce epileptic siezures so soon as vari- 
ations in arterial tone, a fact which might possibly serve to 
explain the matter of atmospheric influence. 

As regarded the pathology of epilepsy there seemed to 
be no permanent lesion of the brain; and all such gross 
changes as had been described by Alexander, by Meynert 
and others, were not the direct cause of the disease. It 
was inconsistent with our clinical knowlege of the disorder 
to seek for visible pathological changes. 



SOCIETY REPORTS 2 I I 

The treatment of epilepsy differed much in its results in 
dispensary and private practice, the former cases existing 
under such bad hygienic conditions. Contrasting the two 
classes, dispensary cases had six times as many siezures and 
were in other ways worse than private patients. There was 
much of value in the character of the aura. Dr. Ingram re- 
ported no aura in 50 per cent, of his cases. Undoubtedly 
the point of departure in epilepsy was critical, and the char- 
acter of the aura gave the seat of the discharge. If the aura 
were visual, as in many cases, the point of origin was in the 
visual area. If auditory, a rarer phenomenon, it began in 
the auditory area. Although the larger proportion of epi- 
leptic siezures was due to cortical disturbances, such dis- 
charge might take place from gray matter anywhere in the 
nervous system. It was unfortunate to condemn the bro- 
mides, for although often injurious, they gave better results 
than any other known drugs, when employed under proper 
regulations. 

Dr. Herter agreed with Dr. Starr that there- was no 
relation between the pathological findings in epilepsy and 
the disease; but nutritive changes in an unstable cortex 
were probably the cause, apart from any gross pathological 
lesions. 

Dr. Fisher thought that the bromides did not interfere 
much with bodily nutrition, as many patients grew fat on 
them. They seemed to become habituated to them. 

Dr. Skinner described a case where the cutting off of 
the bromides resulted fatally. The patient, a young woman, 
had been for some time under bromides, when she was sent 
to an oculist to have her eyes examined. The latter found 
mixed astigmatism. The bromides were cut off. After 
three weeks she began to have petit mal very frequently; 
they became more and more frequent, until finally she sank 
into coma and died. One and one-third grains of morphia 
in four doses hypodermatically made no impression upon 
the siezures. The fits invariably began upon the right side 
of the body, with deviation of the head to the left and of 
the eyes to the right. He thought there had been a cortical 
hemorrhage. 

Dr. LESZYNSKY said that the autopsy in cases of status 
epilepticus yielded no result. Patients died from heart or 
respiratory failure. He believed he had saved the lives of 
several such cases by venesection. He had used nitrite of 
amyl before he knew that it was harmful. Most drugs are 
of no service, with the exception of chloral, which in 40-50 
grain doses per rectum had acted well. The indiscriminate 
use of bromides in epilepsy was injurious, but their careful 
administration was productive of satisfactory results. 

Dr. LYON had employed pilocarpine in a case with epi- 
leptic convulsions, and with excellent results. It produced 



2 I 2 SOCIE TV REPOR TS. 

first a profuse perspiration, after which the patient emerged 
from his attack. In asylums it was very common to with- 
draw the bromides from cases, but he had never observed 
any harm to follow. He had used pilocapine also success- 
fully in a case of hystero-epilepsy. 

Dr. Herter thought pilocarpine should always be em- 
ployed with the greatest caution. He had seen it produce 
pulmonary oedema and death in two cases. 

The PRESIDENT related the case of a barber who several 
years ago began to fall asleep when at his work, and was 
consequently discharged. The somnolent attacks had con- 
tinued. He would fall asleep while walking, or riding on 
the platform of cars, and had frequent falls into the street, 
into gutters, on the stove, etc., none of these things waking 
him up. There was no convulsion, nothing to call epileptic. 
Ten years ago he weighed 150 lbs., now he weighs 270 lbs. 
Curiously enough he was a sufferer from insomnia, not being 
able to sleep continuously at night for more than half an 
hour. Were these epileptic attacks ? Was there any con- 
nection between them and the corpulence ? 

Dr. Dana had reported a case of epileptic morbid som- 
nolence in a young woman several years ago. She had had 
at first only somnolent attacks, later developing real epi- 
lepsy. He believed these somnolent seizures to be a form 
of petit vial. He had had a case similar to Dr. Jacoby's in 
conjunction with Dr. Hammond. He walked about while 
asleep, but did not hurt himself, and could be roused. The 
pupils were contracted as in normal sleep, and not dilated 
as in epilepsy. It might be allied to narcolepsy. 

Dr. INGRAM said that his routine treatment of the status 
epilepticus had been 60 grains of chloral per rectum every 
two hours, and this had been very successful in the majority 
of cases. He had also seen good results and no injury 
from the use of pilocarpine. 

The Committee, consisting of Drs. Peterson, Dana and 
Parsons, appointed at the January meeting to examine the 

GALLUP LUNACY BILL, 
then made its report. (See Report, page 181). 

Dr. STARR expressed himself as thoroughly in sympathy 
with the criticisms and recommendations of the report. 
He moved that the report be adopted and printed and that 
copies be forwarded to the Governor of the State, the State 
Commissioners in Lunacy, and to such others as were 
interested in the insanity laws. 

After some further favorable discussion by Drs. Fisher. 
Leszynsky and Ingram, the report was adopted as read, and 
the recommendations of Dr. Starr ordered. 



gljextr Instruments. 



A TEST OF WILSON'S CYRTOMETER. 

By H. J. MULFORD, M.D. 

Extract from a Thesis, to which honorable mention was accorded, presented to the 
faculty of the medical department of the University of Buffalo in Jan., 1889. 

The cyrtometer was designed for the purpose of locating 
the position of the fissure of Rolando on the living head. It 
is described as follows : 

"The instrument consists of three strips of flexible metal 
and a taper (D, Fig. 1) for securing it in sihi (Fig. 1). The 




1 11 1 1 1 11 1 m 



; II I ' 1 I 1 ITT 



G.TIEMANN &C0 




Fii. 1. — The Cyrtometer. 

broadest transverse strip (A, Figs. 1 and 2) passes coronally 
round the forehead, corresponding with the glabella and 
the external angular process (C and e a p, Fig. 2); the nar- 
rower longitudinal strip (B, Figs. 1 and 2) passes backwards 
from the glabella in the middle line to the occiput. This 
strip is marked with two scales of letters : capitals in its 
posterior fourth, and small letters about the middle of the 
strip (E, e, Fig. 1). 

"Measured from the glabella backwards, the distance to 
any given small letter is 55.7 per cent, of the distance from 
the glabella to the corresponding capital letter ; thus, when 



214 NEW INS TR UMENTS. 

any capital letter falls directly over the inion, the corre- 
sponding small letter will coincide with the top of the 
fissure, A third narrow reversible strip (C, Figs. I and 2) 
slides on the logitudinal slip, making an angle of 67 , open- 




\ 
Fig. 2. — The Cyrtometer in position. 

ing forwards, and marked at 3^1 inches from its attached, 
end (F, Fig. 1), thus giving the length and direction of the 
fissure on the surface of the head." 1 

The following are the scales : 
CAPITALS. 



esf 


rom glabella. 


A 


(H-5) 


B 


(12) 


C 


(12-5) 


D 


(13) 


E 


(13-5) 


F 


(H) 


G 


(14-5) 



SMALL LETTERS. 


Inches from glabella. 


a (6.4) 




- b (6.6) 




c (6.9) 




- d (7-2) 




e (7-5) 




" f (7-7) 




*(*) 




:red a little 


from 



The cyrtometer used by me differed a little from the 
above. It was made of elastic metal ribbon, such as is 
used for clock-springs, without a tape, its own elasticity 
being enough to keep it in position. For this idea I am 
indebted to Dr. Roswell Park, who was then, and is now, 
doing considerable surgery of the brain. 2 

1 Hare, Lancet, 1889. 

2 Park, pamphlet, "Surgery of the Brain, based on the Principles of Cere- 
bral Localization." 



NEW INSTRUMENTS. 



215 
The following 



I applied the cyrtometer to eight heads, 
programme being carried out in each case : 

First. The hair was removed from scalp. 

Second. Cyrtometer was applied over bare scalp. The 
indicated position of fissure was then marked on brain by 
pieces of wood thrust through drill hole in skull wall. 

Third. Scalp and calvarium removed. Brain examined 
to see how near indicated position of fissure approached 
fissure. Length of fissure taken. 

TABLE OF MEASUREMENTS. 







Distance from 


Distance from 




Length of 
fissure. 


Case. 


Sea;. 


glabella to 


glabella to 


Location. 






mion. 


top of fissure. 




1 


Female. 


12.25 in. 


6.8 in. 


Over fissure. 
% inch 


3.5 in. 


2 


Female. 


12.25 " 


6.8 " 


behind fissnre. 
% inch 


4 


3 


Male. 


12.25 " 


6.8 " 


behind fissure. 


4 


4 


Male. 


14 


7.7 " 


Over fissure. 
% inch 


3.75 " 


5 


Male. 


13 


7.2 " 


behind fissure. 


3.75 " 


6.... 


Male. 


12.5 " 


6.9 " 


Ov-r fissure. 


3.75 " 


7 


Male. 


12.5 " 


6.9 " 


Over fissure. 


3.75 " 


8 


Female. 


12.5 " 


6.9 " 


Over fissure. 


3.5 '• 



In three (all male) the cyrtometer was absolutely cor- 
rect. 

In two (both female) correct in all but length. 

In one (male) one-eighth inch behind fissure. Length 
correct. 

In one (male) one-eighth inch behind fissure. One- 
fourth inch shorter than fissure. 

In one (female) one-fourth inch behind fissure. One- 
fourth inch shorter than fissure. 

In not one did the fissure of Rolando open into the 
fissure of Sylvius ; 3 neither was there found a convolution 
bridging the fissure of Rolando. 4 

Of the various methods proposed for locating the fissure 
of Rolando, I think Mr. Hare's the best, for these reasons : 

First. The cyrtometer is quickly applied and easily 
retains its place. There are no planes to determine, no 
lines to draw, and but two landmarks are necessary. 

Second. It is as correct as any method can be in the 
present fashion of heads. Its errors are small, and when 
they occur need not be feared. I would advise its use. 



3 Turuer. 



* Fere. 



g00fcs 2tec*it»ed. 



American Resorts, with Notes upon their Climates. By Bushrod 
W. James, AM., M.D. Philadelphia and London, 1889. 
F. A. Davis. 

Extra-Uterine Pregnancy— A Discussion. Reprinted from the 
Transactions of the American Association of Obstetricians and 
Gynaecologists: Philadelphia, Wm. J. Dornan, Printer, 1889. 

Practical Lessons in Nursing Diseases and Injuries of the Ear 
Their Prevention and Cure. By Chas. Henry Burnett, A.M., 
M. D. Philadelphia, J. B. Lippincott Co. 

A Treatise on Headache and Neuralgia. Including Spinal Irri- 
tation and a Disquisition on Normal and Morbid Sleep. By 
J. Leonard Corning, M. A., M. D. With an appendix : ' Eye 
Strain a Cause of Headache By David Webster, M.D. 
Illustrated. Second edition. New York. E. B. Treat, 5 Coop- 
er Union. 

A Text-Book of Mental Disease, with Special Reference to the 
Pathological Aspects of Insanity. By W. Beaver Lewis, L.R. 
C. P., M.R.C.S (London, Eng. : Philadelphia, P. Blakiston Son 
& Co., 1890. 

Spinal Concussion — Surgically considered as a cause of spinal 
injury, and neurologically restricted to a certain symptom- 
group, for which is suggested the designation, Erichsen's 
Disease, as one form of the Traumatic Neuroses. By S. V. 
Clevenger, M.D. Philadelphia and London. F. A. Davis, 
publisher, 1889. 



NOTICE. 
THE AMERICAN NEUROLOGICAL ASSOCIATION. 

The Council of the AMERICAN NEUROLOGICAL ASSO- 
CIATION have decided that the Sixteenth Annual Meeting 
of the Association will be held at Philadelphia, Pa., on 
Wednesday, Thursday and Friday, June 4th, 5th and 6th, 
1890. 

There will be two daily sessions, one at 10.30 A. M., the 
other at 3.30 P. M. 

Dr. G. M. Hammond. 
Secretary s Office, 

58 West 45TH Street. 



VOL. XV. April, 1890. No. 4 

THE 

Journal 

OF 

Nervous and Mental Disease. 



©rirjttrat Articles. 



A CASE OF OPHTHALMIC MIGRAINE. 1 

By J. CHALMERS DA COSTA, M.D. 

THE association of diverse nervous phenomena with 
many cases of migraine has long been recognized by 
the profession. 

Latham speaks of colored glimmerings occurring to the 
outer side of the visual field, with an inability to see some 
objects in the field. 

Abercrombie compiled many observations of curious 
motor phenomena, spasmodic and paralytic. 

Gowers speaks of aphasia being associated with migraine 
and numbness of the right side. 

Da Costa speaks of its association with numbness and 
anaesthesia of an extremity. 

Prony and Fere mention migraine linked with numbness 
of the hand and tongue, temporary aphasia, and epileptiform 
attacks. 

Charcot points out hemianopsia and aphasia. 

Weir Mitchell noted hallucinations. 

Dr. Laundly, of London, has recorded a most remark- 
able case of recurrent migraine, in which during the attack 
there was paralysis of the third nerve of the left side, ptosis, 
absolute paralysis of the superior, inferior, and internal 
recti, pupillary dilatation, and paralysis of accommodation. 

1 Read before the Philadelphia Neurological Society, February 24, 1890. 



2l8 J. CHALMERS DA COSTA. 

Recovery after each attack was not absolute. The superior 
rectus became permanently paralyzed, and the other two 
recti weakened, and some degree of ptosis persisted. 

Other observers have spoken of migraine being occa- 
sionally associated with perturbations or affections of taste, 
smell, hearing, loss of consciousness (partial or complete), 
vertigo, temporary hemiplegia, and transient blindness. 

It is thus manifest that anomalous symptoms, if not fre- 
quent, are at least not unusual ; but, in spite of this, I beg 
to present a case, probably not new to my auditors, but 
which to me was novel and peculiarly interesting. 

A single woman, aged thirty-two, of a melancholy tem- 
perament and nervous diathesis ; has passed the menopause. 
Family history is neurotic, the mother having had neural- 
gia and Jiaving been hypochondriacal. The father died of 
phthisis. Ever since her childhood she has had attacks of 
sick headache, coming on at irregular intervals, a month 
occasionally intervening. The attacks would terminate in 
vomiting, and were not connected with menstruation. 

About two years ago the menses ceased, and the attacks 
of pain began to appear, with some degree of regularity, 
about every three weeks. The attacks are preceded for 
some hours by dull, unlocalized headache, anorexia, nausea 
and languor. 

The eyes feel heavy and weak, and light is unpleasant. 
Muscat volitantes flit before the right eye, followed by col- 
ored spectra, flashes of light, and a scintillating scotoma. 
Intense paroxysms of lancinating pain occur in forehead, 
temple, and eye of the right side. There is marked photo- 
phobia, the eye is red, the pupil is dilated, and reacts slowly 
to light. 

After some hours the paroxysms occur so frequently as 
to seem almost continuous, violent vomiting sets in, and the 
patient, apparently from exhaustion, falls into a profound 
sleep. 

On several occasions, with the appearance of the sco- 
toma, she has had numbness, pins and needles, and formi- 
cation of right arm, lasting until termination of seizure, and 
accompanied by marked muscular weakness. 

Again, anaesthesia of right arm has been observed, last- 
ing for many hours. 

Several times hemianopsia has replaced the scotoma, 
the right lateral half of each visual field being lost. 

On one occasion the vomiting was not followed by sleep, 
and for many hours marked paraphasia existed. 



OPHTHALMIC MIGRAINE. 2 1 9 

To sum up : 

Occasional transient aphasia ; transient hemianopsia ; 
numbness, anaesthesia, and muscular weakness in right arm, 
violent pain in ophthalmic division of the fifth nerve, scin- 
tillating scotoma and vomiting, occurring with more or less 
regularity, in a woman of middle age, of a nervo-melancholy 
temperament, and in poor general health. 

The existence of such symptoms leads us to look for an 
explanation. 

Dr. Liveling maintains emphatically that migraine and 
epilepsy are closely related. 

An attack of migraine, he tells us, is due to an accumu- 
lation of nerve force and unstable nerve elements, the 
accumulated force reaching a high degree of tension, and 
exploding in a storm of pain. 

According to this view, an explosion upon the motor 
sphere means epilepsy ; on the psychic sphere purely, epi- 
leptic mania ; and on the sensory sphere, neuralgia. 

Liveling believes the fundamental cause of migraine to 
be "a primary and often hereditary vice of the nervous 
system," and the seat of this nerve instability to be in the 
optic thalami and parts between them and the roots of the 
vagi. 

Dr. Stevens of New York, on the contrary, looks to 
reflex peripheral irritation as a cause of migraine, and insists 
that in most instances he finds this cause to be due to errors 
of refraction or accommodation. 

Dr. Ringer forms a class of diseases, which he calls the 
explosive neuroses. This includes ordinary neuralgia, teta- 
nus, asthma, epilepsy, migraine, epileptic mania, etc. These 
are due to a weakening of the nervous power of control, 
to a loss of resisting power, so that irritations which should 
cause impressions limited to small and definite areas, cause 
impressions which diffuse, spread out, flow over wide and 
often distant regions, producing symptoms according to the 
region attacked. 

Take a case of ophthalmic migraine. The irritation 
causes primarily a flow of force from the nucleus of the fifth 
in connection with the ophthalmic division. As resistance 



220 7- CHALMERS DA COSTA. 

is weakened this force flows back to the nucleus of the 
pneumogastric, and vomiting occurs. 

If the discharge is excessive in power, or if the resistance 
is much impaired it will flow to more distant points and 
produce symptoms of the most variable nature (sensory, 
motor, and psychic). 

I would inquire of the Society as to the future of a patient 
with ophthalmic migraine, especially of this form. Is mi- 
graine ever a prodrome or early symptom of serious organic 
mischief. 

Charcot says that the future of a subject of severe 
migraine is always uncertain. The attacks may recur for 
years and even pass away entirely, no other trouble being 
manifested, but in some cases it is a precursor of general 
paralysis of the insane. 

Duchenne considers migraine a not unusual prodrome 
of tabes dorsalis, and Oppenheim of Berlin found it present 
in twelve tabetics out of eighty-five. 

And finally Austie, noting that neuralgia might precede 
paralysis of a part, states his belief to be that neuralgia is 
the first expression of a condition which tends to become 
paralysis. 

CLASSIFICATION OF MENTAL DISEASES. 

The "Glascow Medical Journal," February, 1890, quoting 
from the "Annales Medico-Psychologiques," September, 
1889, states that the following classification was presented 
to the International Congress of Mental Medicine, held in 
Paris last August, and adopted as a basis for international 
statistics : 

1. Mania, comprising acute delirium. 

2. Melancholia. 

3. Periodic insanity (double form, etc.). 

4. Progressive systematized insanity. 

5. Secondary dementia. 

6. Organic and senile dementia. 

7. General paralysis. 

8. Neurotic insanities (hysteria, epilepsy, hypochon- 

dria, etc.). 

9. Toxic insanities. 

10. Moral and impulsive insanity. 

11. Idiocy. L, F. B. 



REMARKS ON THE PATHOLOGY OF CHOREA. 1 

By E. D. FISHER, M.D. 

IN an article in the " Lancet," 1889, Dr. A. E. Yarrod 
describes in cases of acute chorea of rheumatic origin, 
an increase of connective tissue in the cerebral cortex. 
This pathological condition accords with the clinical aspect 
of the disease, acute or chronic, as one of the characteristic 
features of chorea is the increase of movement on any exci- 
tation of the will. In other words, call the cerebrum into 
action by concentration on any special motor act, and as a 
result motor disturbance ensues. 

Another marked symptom is the constant motor dis- 
turbance, which ends only with sleep, a fact significantly 
pointing to the cortex cerebri as the primary seat of the 
lesion in chorea. We have here to do with a disease whose 
principal symptom is an affection of the motor apparatus. 
What is clearly seen is that we have a loss of the normal 
inhibitory action of the cerebrum. 

The constant motor disturbance in some acute cases is 
due to the irritant effect of the connective tissue — that is, if 
we accept Yarrod's theory ; and this is probably very often 
due to a rheumatic diathesis. 

In chronic chorea we have a lesion resembling that of 
multiple sclerosis, although less coarse in character. Diller, 
in the " American Journal of the Medical Sciences," Decem- 
ber, 1889, well defines it as a fine general sclerosis. We 
may have patches of degenerated nerve-tissue, the result 
of diseases of the vessels, causing ansemia and interference 
with the nutrition of nerve cells and fibres. 

This leads to irregular stimulation of the motor tracts. 
We do not as a rule get actual paralysis nor indeed the 
increased reflexes following secondary degeneration in the 

1 Read before the New York Neurological Society, March 4, 1890. 



222 E. D. FISHES. 

cord. We almost always find, however, some paresis, and 
one of the symptoms present in multiple sclerosis, mental 
dullness. Arndt affirms that there is always some mental 
disturbance in chorea. In chronic cases it is especially 
marked, as also in hereditary chorea. 

In Mercier's paper on " Inhibition," in " Brain," October, 
1888, he compares the nervous system to an army under its 
different officers ; the loss of any one of these heads leads 
to disorder in some of the various departments. This idea 
has always seemed to me too mechanical. In the nervous 
system we have to do with living organisms ; their action 
or function is continuous, and dependent on their nutrition. 
The higher centres are subject to constant influence from 
without, through their lower centres and nerve-paths, and 
this manner a constant relation or equilibrium of all the 
various parts of the nervous system is maintained. There 
is continuous action going on in the central ganglia, it is 
not only expended in the carrying out of some motor 
effect. 

Let the peripheral stimuli become excessive, and these 
centres become exhausted, and as a result irregular effer- 
ent impulses are sent to the motor apparatus, as seen in the 
different occupation neuroses. I agree with him that no 
general or special inhibitory centre exists, but rather that 
the control or inhibition lies for each part in its correspond- 
ing centre. 

An irritable condition of a centre, produced mechanically 
or through nutritional changes, may result in the so-called 
explosion of that centre, as in an epileptic seizure, or again, 
as in chorea, we may have continuous efferent impulses sent 
to the motor apparatus when no voluntary act is being 
carried out. When the lesion is more extreme, inhibition 
is still more affected, and purposive action only the more 
forcibly brings out the irregular motor effects. 

It is possible, therefore, that lesions involving the nerve- 
tracts as well as the nerve-centres may be considered as 
causing chorea, thus allying it to multiple sclerosis ; al- 
though when we remember that it is the muscles of special- 
ized action — /. e., of the hand — which are first and most 



PA THOL OGY OF CHOREA . 223 

severely affected, it is probable that the primary lesion is in 
the cerebral centres controlling those parts. 

In paralysis agitans we have a tremor which may be 
inhibited, and, if we accept Dr. Broadbent's theory of the 
seat of the lesion in this disease as lying in the muscular 
nerve-endings, we can readily understand the reason why 
this is so : the primary lesion points away from the cortex, 
whatever the secondary changes may be. 

In acute chorea we find anaemia and vaso-motor changes 
more often present than any other condition. 

Hanford, in " Brain," , 1889, quotes Dr. Dickinson 

as ascribing acute chorea to a widely spread hyperaemia of 
the nervous system, and in his own two cases he found, 
post-mortem, numerous haemorrhages of the brain and cord 
with thrombosis and dilatation of the small vessels and 
capillaries. He considers the spinal cord, rather than the 
cerebral cortex, as the primary seat of the disease, as he 
believes the movements can be controlled in at least mild 
cases. 

The connection of chorea and rheumatism is certainly 
more than accidental, but at the same time I do not believe 
it is as frequent as many writers would have us believe. 

In chronic chorea we can look for atrophy of the cortex 
and degenerative changes in the nerve-tracts as a result of 
the hyperaemia and extravasations found in acute chorea. 
In support again of this theory I would refer to two cases 
reported by M. D. McLeod, in the "Journal of Mental 
Sciences," July, 1881, of two sisters, the chorea commencing, 
in the first, at the age of sixty ; the autopsy revealed a cyst 
under the dura mater, over the left hemisphere, with flatten- 
ing of the convolutions. The second sister was affected at 
the age of seventy, and the autopsy showed multiple tu- 
mors, with compression of the cortex. In these cases the 
compression and atrophy produced the chorea. 

Dr. A. B. Ball, in an interesting paper on " Thrombosis 
of the Cerebral Sinuses and Veins," in the " Transactions 
of the Association of American Physicians," vol. iv„ refers 
to this condition as occurring in chlorosis in young women, 
and reports several fatal cases with autopsies. The author 



2 24 £■ £>■ FISHER. 

makes no reference to the occurrence of chorea in these 
cases, but that such a thrombosis may result in atrophy of 
the convolutions from permanent occlusion of the veins, 
entering the longitudinal sinus in the same manner as de- 
scribed by Gower, in cerebral spastic hemiplegia in children, 
seems to me very probable, although I cannot refer to any 
autopsies in proof of it. 

Certain it is that in just such cases of chlorosis we find 
chorea unassociated with rheumatism or cardiac disease. 
The acute cases recover with the re-establishment of the 
circulation, while chronic chorea results from the atrophies 
referred to. 

Acute chorea is as curable, therefore, as the conditions 
causing it, while in chronic chorea the prognosis depends 
on the character and extent of the lesion. The folly, there- 
fore, of ascribing to the removal of a peripheral irritation, 
such as eye-strain, the possibility of effecting a cure in 
chronic chorea — that is, if we accept the pathology of it as 
just given — is apparent. 

My paper has referred especially to the pathological 
changes in chronic chorea, and has emphasized the primary 
seat of the lesion as lying in the cortex cerebri. 



UNILATERAL ABSENCE OF KNEE-JERK — PATHOLOGICAL 
FINDING IN A CASE. 

Dr. A. Pick (Arch. f. Psych., 1889, vol. xx ) reports a 
case in which a diagnosis of tabes and dementia paralytica 
was made. The symptoms were : girdle sensation, reten- 
tion of urine and faeces, slight paresis of the left facial 
nerve about the mouth, unsteady gait, tremor of the tongue, 
delusions of grandeur, etc. The knee-jerk was absent on 
the left side, and only to be elicited by reinforcement upon 
the right. 

Autopsy: Chronic internal hemorrhagic pacyhmeningi- 
tis, chronic inflammation with thickening of the other mem- 
branes, atrophy of the brain. Degeneration in the cord on 
the border of the columns of Goll and Burdach from the 
lower cervical region down. In the upper dorsal region 
there was on the left also a narrower stripe next to the 
posterior horn, and on the right a similar one in the middle 
of the column of Burdach. In the lower dorsal and in the 
lumbar portions of the cord, on the left side, the posterior 
root zone was affected. F. P. 



SPECIMEN SHOWING ANOMALY OF THE CIRCLE 
OF WILLIS. 1 



By JAMES HENDRIE LLOYD, M.D., 

THE specimen was taken from an insane man, who died 
in the Philadelphia Hospital — a case of chronic mania- 
In the large number of brain-dissections which I have 
seen or conducted, this is the first time I have met with an 
anomaly of the circle of Willis, although such anomalies 



m JM, Ccu/sff brd*£ hnfHA/^OxWJs 




Stdi 






\f ^\V>. QjlnroV 






W^I 






\\ R;Ve*V (oii^J 



are not uncommon. This anomaly under some circum- 
stances might be of clinical or pathological interest, and 
will be best illustrated by a diagram. Ordinarily the two 
1 Presented to the Philadelphia Neurological Society, January 27, 1890. 



2 26 JAMES HENDRIE LLOYD. 

vertebral arteries unite to form the basilar ; in this case the 
right vertebral artery did not exist. The basilar artery 
was a continuation of the vertebral artery of the left side. 
It sent off as usual the posterior cerebral artery. The 
posterior communicating artery on the left side was a very 
large trunk ; in fact, this was one large continuous vessel 
from the foramen magnum. The left internal carotid then 
divided into the middle cerebral and the anterior cerebral. 
The anterior cerebral arteries of both sides sprang from this 
one trunk. Practically more than one-half of the brain was 
supplied from this one side. On the other side the carotid 
gave off as usual the posterior communicating artery, which 
is a large trunk, in this case practically continuous with 
the posterior cerebral artery. The branch of the basilar, 
which as a rule forms the posterior cerebral artery, is here 
small, rudimentary, and probably non-pervious, as is also 
the branch of the carotid, which ordinarily forms the 
anterior cerebral. 

This anomaly is described by Duret. One singular 
thing is that the branching of the posterior cerebral from 
the carotid generally takes place on the right side. The 
vertebral artery of the left side is usually the largest, and 
when only one is present it is apt to be the artery of the 
left side. The only apparent reason for this is that the left 
vertebral artery derives its supply more directly from the 
subclavian than does the right vertebral. What pathologi- 
cal interest this anomaly has I cannot say. Embolism 
in such a case might give rise to some peculiar symp- 
toms ; but I doubt if the condition could be recognized in 
life. 



THE FUNCTIONS OF THE BRAIN. 
The doctrines of the Italian school are embodied in the 
first part of a paper (fifty pages) by Jules Soury in the 
November number of the "Archives de Neurologic" The 
cortical centres for cutaneous and muscular sensibility and 
for voluntary movements are considered. 

HYSTERO-EFILEPSY IN BOYS. {Ibid.) 
The history of three cases forms a contribution to the 
study of this subject, by Bourneville and P. Sollier. L.F.B. 



FUNCTIONAL NERVOUS DISEASES AND THEIR 

RELATIONS TO GASTRO-INTESTINAL 

DERANGEMENTS. 1 

By W. H. THOMSON, M.D., 

Prof. Materia Medica, University Med. College, N. Y.; Physician to Bellevue and Roosevelt 

Hospitals. 

A S a teacher of the materia medica it has long been my 
jh\^ practice to divide all medicines proper into two 
great classes, namely, the organic and the func- 
tional. The organic medicines are those whose special 
remedial action can never be secured by one dose, but only 
by the slowly cumulative effects of many repeated doses. 
The functional medicines, on the other hand, are those 
whose whole specific action is obtained by one dose, and 
no repeated doses of them ever effect more than did the 
first dose. Iron given for anaemia or mercury for syphilis 
are examples of the organic medicines : opium and bella- 
donna are examples of the functional medicines. The 
organic medicines are given for the diseases or morbid 
conditions themselves and not for their symptoms. The 
functional medicines are given for the symptoms and for 
nothing else. If, therefore, potassium iodide relieves the 
pain of a syphilitic node, it is because it removes the node 
itself. If opium, on the other hand, relieves the same pain, 
the node, still remains to renew the pain so soon as the 
effect of the dose has worn off. The organic medicines 
should not produce any symptoms of their own. If they 
do, they are not producing their remedial effects. The 
patient should not know that he is taking anything, except 
by signs of returning health. The functional medicines, on 
the contrary, do nothing but produce symptoms. Organic 
medicines show no effects, that is, not the effects for which 

1 Read before the County Medical Society ot New York, Jan. 27, 1890. 



2 28 W. H. THOMSON. 

they are given as remedies, except in states of disease. 
Iron does not increase the strength of a healthy man, and 
no healthy man will show any beneficial effects from mer- 
cury such as a syphilitic person does. But functional 
medicines show the same symptoms in health as in disease. 
Strychnia does not need an invalid to illustrate its proper- 
ties, and an emetic will act in its proper dose on the most 
normal stomach. 

Time will not allow still other contrast, to be presented 
between these two classes of medicines, but what has been 
adduced suffices to show that there is this fundamental 
difference between them, namely, that by the slow cumula- 
tive action of the organic medicines we produce organic 
changes in the nutrition of the body, either in its fluids or 
in its solid tissues. By the functional medicines we produce 
no organic change whatever. By repeated dosing with 
them we only do over and over again what we did with the 
first dose. Functional medicines, therefore, never cure any 
disease. The most they can ever do is occasionally to 
break a nervous habit. Hence, as the neurotics belong to 
the class of functional medicines, no true nervous disease 
can be cured by a neurotic. All a neurotic does in any 
nervous disease is to relieve some symptom of that disease, 
leaving the disease itself the same as before. A man may 
have taken a thousand doses of stramonium for his asthma, 
but the thousandth dose can do no more than the first dose 
did, namely, relieve the symptom spasm, but in no way 
modify the disease (asthma) itself. 

The only difficulty which I have experienced in demon- 
strating these principles has arisen from a slowness on the 
part of some minds to recognize what the difference between 
the function of an organ and the organ itself is. How an 
agent, for example, like veratrum viride, or like digitalis, 
can act on the function of the heart and not on the heart 
itself, is to them puzzling. But this should be no more 
puzzling than the common fact that a man may act on his 
brain for years with powerful doses of opium or of tobacco 
and yet not affect that organ itself enough to furnish the 
least clue for the most skilled microscopist to distinguish 



FUNCTIONAL NERVOUS DISEASES. 220, 

the brain of an opium or tobacco smoker from that of one 
who never took either of these poisons. For this difficulty 
the most commonly advanced hypothesis is that specific 
organic changes doubtless are caused in nerve tissue by 
these strong poisons, but that these are of such a molecular 
character that we have not yet attained to the requisite 
methods for their detection. That there must be some 
change induced is taken for granted as almost a self-evident 
proposition resulting from the supposed necessity that for 
every manifestation of nerve function there must be a cor- 
responding physical basis in nerve matter. Moreover, this 
conception seems to be further supported by the undoubted 
fact that structural changes in any organ, including nervous 
organs, always manifest corresponding functional derange- 
ments, and therefore we may suppose the converse to be 
also true, namely, that functional derangements always 
have their corresponding structural changes. 

But a little reflection on what function in distinction 
from structure really is may suffice to show that function 
may be either deranged or wholly arrested without structure 
being involved at all. For the function of an organ consists 
in the work that it does and in that alone. But for the 
working of any organ, or for that matter for the working of 
any mechanism, not only is structure needed, but something 
plus structure. Respiration, for example, is the function of 
the lungs, secretion that of a gland. Now we can either 
stimulate or decrease that working without affecting even 
molecularly the texture of the lung itself or of the gland, 
just as we can increase the working of a steam-engine by 
adding more coal, or stop it by putting the fire out, without 
in either case affecting the structure of the iron mechanism 
itself. In an oil-lamp also we may have its function of 
giving light much disturbed by adulteration of its oil, from 
diminution of its light to veritable explosion, without its 
own mechanism, either in its wick or in any other part of 
its apparatus, having anything wrong about it. It is just as 
true in this case that any damage to the structure of the 
lamp may correspondingly affect its light-giving function, 
but that does not prove that whenever it is disturbed in its 



23O W. H. THOMSON. 

lighting power some alteration must have happened in its 
structural parts. 

The lamp needs for its function good structure first, but 
also something else. The nerve-cell likewise needs normal 
specially differentiated protoplasm first, but also something 
else, and which something else may be so deficient or 
deranged that the cell function will be correspondingly 
abnormal, no matter how normal the protoplasm itself be. 

I do not see why, therefore, these illustrations do not 
hold good in the case of functional derangements in the 
living mechanism. We have a number of affections which 
in the last analysis seem to be wholly disorders of function. 
We say last analysis, because no methods yet discovered of 
investigation carry us farther than the determination of a 
functional derangement. Every known mode of examining 
structure fails of demonstrating in them the least character- 
istic departure from structural integrity ; and yet to many 
minds it seems unphilosophical to rest content with the 
term "functional." They insist that every functional de- 
rangement must have a corresponding anatomical change 
to which it is due and which will account for it, and they 
look forward to the time when the progress of our knowl- 
edge will banish the term functional from medical termin- 
ology altogether by giving us in the case of epilepsy, 
hysteria, migraine and other now-named functional affec- 
tions the proper anatomical designation for them. But this 
view arises wholly from the conception that nerve-cells 
work spontaneously by virtue of their organization, and 
therefore that when they seem to work abnormally some- 
thing must have gone wrong with the arrangement of their 
physical molecules. It seems to be overlooked that with- 
out a constant supply of a material or materials for their 
working, nerve-cells must remain as inactive as a gun 
without its powder. If the powder be too small in quantity, 
or defective in making, or has been wet, all the unsatisfac- 
tory working of the gun therefore was from no fault in it, 
and why may not a nerve-cell work badly from no fault in 
it, but solely from deficient or poisoned function pabulum ? 

This question is not one of theoretical, but of practical 



FUNC TIONA L NEK VO US DISEA SES. 2 3 I 

importance. If every functional nervous disease is really 
due to a definite morbid change in either nerve-cell or 
nerve-fibre, then we must continue to search in nerve-cell 
or in nerve -fibre for that change and for its causation. If, 
however, such nervous affections are not at all to be traced 
to faults of structure, but rather to disordered sources of 
nerve energy, then we must look elsewhere than to the 
nervous system for both the causation and for the remedy- 
ing of these disorders. But in examining the conditions 
under which manifestations of energy take place, we are 
met at the outset by the fact that the relations of energy to 
structure are in no instance yet known to science, not even 
in the so-called mechanical forces. Our knowledge of such 
relations is purely empirical. Why electricity, for example, 
will traverse an iron rod but not a glass rod, we neither 
know nor can explain. It does not seem philosophical, 
therefore, to expect that in the case of nerve-function we 
are going to discover its structural relations any easier, and 
certainly not in disordered function, when we have not the 
slightest clue to the physical basis of a normal sensation, 
or of a motor impulse or of a thought. The structure of no 
mechanism for the utilization of energy ever gives the least 
indication, to one who inspects it, of what the thing is 
which energizes it. All he can do is to note its mode of 
working. And this is also all that one can do in those 
disorders of nerve-function which we can induce artificially 
by administering functional medicines. What it is that 
hydrocyanic acid does to a group of cells in the medulla 
we can only tell by describing the resultant disturbances of 
nerve-working, and there we must stop. But equally in 
those functional disturbances which cause a convulsion or a 
neuralgia, all we can do is to observe rather than to 
explain. We are not even assisted by noting how much 
the structure is worn by its working. Liebig erroneously 
thought that the energy of the muscle-cell was generated 
by its own self-expenditure, and hence that muscular exer- 
tion might be measured by the amount of urea formed, and 
there are some who still speak of the nerve-cell generating 
its force by using itself up in the process. But we now 



232 W. H. THOMSON. 

know that we might as well explain the flight of a bullet by- 
noting how much the gun was worn by its discharge. 

Regarding our subject, therefore, from the empirical 
standpoint of clinical observation, which is the only prac- 
tical one, the question then arises, are there any features 
which distinguish supposed functional nervous diseases as 
a class so plainly that we can conclude from these features 
that they are distinct in kind from organic nervous diseases? 
If so, what is the significance of those distinctions, and to 
what conclusions do they point as to the essential char- 
acters of these disorders? 

There is one distinction which has always seemed to me 
of fundamental import, and it is this: that no structural or 
organic nervous disease is ever truly intermittent. A hemi- 
plegic may show a greater degree of weakness one day 
than another, but he is always hemiplegic nevertheless. 
A patient with fully developed locomotor ataxia may vary 
considerably in his symptoms from day to day, but never is 
he so much better that no one would be able to detect a 
sign of disease in him. And so with any of the other ner- 
vous diseases characterized by structural changes in nerve- 
tissue. Indeed it is inconceivable how it can be otherwise. 
A positive loss or degeneration in nerve-cells or nerve- 
fibres must show as closely corresponding defects in the 
use of those textures as in the case of loss or degeneration 
in muscle or bone. But quite otherwise is it with true 
functional nervous diseases. The most skilled nervous 
specialist may be wholly unable to suspect that a man 
whom he meets in company will within an hour terrify the 
room full of people by falling in a violent epileptic fit ; or 
that the vivacious lady near him Avill be prostrated the next 
day with a severe sick-headache. Nothing, in fact, seems 
more complete than the disappearance of all signs of any 
disease, nervous or otherwise, in many patients with pro- 
nounced and definite functional nervous affections during 
the intervals between their attacks. We might as' well 
expect to detect by our means of exploration whether a 
given person be avaricious or generous as whether, in many 
typical cases of functional disorders, they are subject to 



FUNCTIONAL NERVOUS DISEASES. 233 

convulsive or to neuralgic paroxysms, and it is probable 
that anatomy will never be able to tell us how these fits 
happen according to structural nervous changes, until it is 
also able to give us the structural anatomy of cupidity or 
of benevolence. 

But as it is difficult to imagine how an organic nervous 
disease can be ever truly intermittent, so it follows that a 
truly intermittent disease cannot have an organic basis in 
the nervous system. This proposition is in no way invali- 
dated by citing those cases of epilepsy which accompany an 
organic lesion within the cranium, such as a pachymenin- 
gitis, syphilitic or traumatic, and which in some instances 
have been relieved by a surgical operation. All that can 
be said for the causation of the epilepsy in such instances 
is that any abnormal or simply unusual afferent impression, 
whether proceeding from an intercranial or from an extra- 
cranial focus, may cause epilepsy ; as, for example, a case 
of severe and protracted epilepsy which supervened upon a 
wound of a testicle and which was cured by the removal of 
that testicle. Every afferent impression to which the affected 
nerve-centres are wholly unaccustomed may be dangerous 
in this way, as witness the numerous published cases of 
fatal status epilepticus caused by injections for washing out 
the pleura and also after washing out the stomach. In fact 
organic changes within the skull, if they occasion epilepsy, 
do so on just the same principle that a tapeworm in the 
intestine may do likewise, and they do not, therefore, afford 
any indication that this functional disease has at any time a 
true specific organic basis. 

If, therefore, we have any supposed functional nervous 
disease, whose manifestations are continuous, and not inter- 
mittent, the presumption becomes strong that it has an 
organic basis, even though such has not been yet demon- 
strated. Paralysis agitans, for example, comes within this 
category, and recent investigations seem to render this 
surmise correct. Chorea, on the other hand, will, we think 
turn out to be an exception which proves the rule. The 
presence of a toxic element in the blood, rather than of an 
organic change in the nervous system, is becoming more 



234 W. H. THOMSON. 

and more probable as the commonest cause of this affection. 
The great frequency of carditis in choreics, as shown by 
Osier, even though they have never given a history of 
rheumatic seizures, strongly supports the view, which I have 
long held, that the rheumatic poison may, in early life, 
manifest itself in no other way than by nervous symptoms. 
In the case of gout, we know that its poison often ceases in 
the adult to develop articular symptoms and to attack 
nerve-centres instead. I have a patient who can date the 
particular day, more than ten years ago, on which that 
happened after a profound nervous impression, and he has 
been troubled ever since with the most intractable and 
varied functional nervous disturbances. That the nervous 
system of children may therefore be specially susceptible 
to the rheumatic poison, more so than their articular tex- 
tures, has nothing inherently improbable in it, especially as 
with numbers of them we find the heart also more readily 
affected than the joints. In common with many other ob- 
servers have I been repeatedly struck with the proneness of 
some children to develop carditis when other signs of the 
presence of rheumatism, including arthritis, were but little 
pronounced, and this fact alone takes away much of the 
value of some statistics which have been published of the 
occurrence of chorea without rheumatic antecedents. The 
case indeed just cited, of the transference of gout from the 
joints to the nervous system from nervous shock, suggests 
an analogy with the often alleged origin of chorea from 
fright. 

In severe acute functional nervous diseases, the profes- 
sion, following the clue afforded by hydrophobia, has been 
led to look elsewhere than to the nervous system for the 
specific cause, and in the case of tetanus has found it. But 
on the same principle we ought to search likewise for the 
cause of Landry's paralysis. Anyone under the domina- 
tion of the anatomical theory, who may see a case of this 
formidable disease and then watch the steady but speedy 
ascent of the palsy until bulbar symptoms successively 
develop, will feel sure that a fearfully rapid disorganization 
of nerve-centres is progressing under his observation. But 



FUNCTIONAL NERVOUS DISEASES. 235 

after death nothing is found in either the peripheric or in 
the centric divisions of the nervous system that tells any- 
consistent story. One or two isolated observations of limi- 
ted peripheric changes comprise all the trustworthy ner- 
vous pathological anatomy of acute ascending paralysis. 
Other examinations by most competent investigators have 
shown no more certain indications how death was caused 
than examination of the medulla shows how hydrocyanic 
acid kills. On the other hand, I once had a patient with that 
toxic paralysis which follows diphtheria, die with many of 
the typical symptoms of Landry's paralysis. And it is not 
without significance that in nearly every autopsy of this 
affection, enlargement of the spleen, and often of the mesen- 
teric glands, has been found, suggestive of a poison in the 
blood, rather than of an organic nervous mischief as an 
explanation of the mortal issue. 

If, therefore, such acute functional affections, severe 
enough to be terribly fatal, run their course without a sin- 
gle characteristic change in nerve tissue, we can scarcely 
expect this change in the chronic varieties of functional 
diseases which have their long intervals of complete ces- 
sation. During these intervals, the nervous system goes on 
with as little sign of disturbance or of interference as it 
does in a man who gets intoxicated with alcohol only once 
every few weeks or so. But while this great feature of 
intermittency is utterly at variance with any theory of 
structural alteration that can be framed, it is not incompat- 
ible with certain facts which the study of functional medi- 
cine affords. By neurotics we can artficially induce some 
close imitations of functional nervous diseases, and cause 
delirium, convulsions, comas, neuralgias, paralyses and all 
intermediate symptoms of the kind, and note these symp- 
toms disappear in about the time and order that a functional 
nervous attack develops and declines. The feature of in- 
termittency would then correspond to the intervals of 
intoxication in this respect, namely: that with analogous 
periodic doses of opium, for example, we would have re- 
current attacks of functional derangements, giving just the 
same symptoms each time, with no new element developing, 



236 IV. H. THOMSON. 

just as functional nervous diseases recur for years without 
indicating that ominous feature of progressive extension 
which goes with most organic neuroses. 

So far, the analogy is good enough, but it may be well 
urged that the toxic theory of functional neuroses can 
hardly hold good for those cases which are associated with 
a palpable organic focus of irritation, as epilepsy from mal- 
formation of the skull, or from a pachymeningitis, or in a 
reflex case, from a renal calculus, etc. Is it to be supposed 
that such permanent exciting causes of the convulsions act 
by generating poisons ? To this it may be replied that the 
problem of intermittent derangements with permanent ex- 
citing causes is no better explained by any other theory than 
that of a concurrent toxic influence, for the permanent irri- 
tant cannot of itself be enough to cause the convulsion, else 
the convulsion would neither intermit nor cease, but be as 
continuous as the irritant is. There is in every such case, 
the irritant and something else, and not till both act simulta- 
neously does a convulsion occur. It is, therefore, just as 
easy to explain the case by saying that the permanent irri- 
tation acts by developing an idiosycransy to the operation 
of certain recurrent poisons in the blood which did not 
exist before the irritation. This is by no means a fanciful 
hypothesis, for the relation of the subject of idiosyncracies 
to neurotics can be shown to have a much closer relation to 
the phenomena of functional neuroses than any anatomni- 
cal facts can. Without the slighest indication to forewarn 
us, we may kill a patient with an insignificant dose of chlo- 
ral or of antipyrine, and in a less degree we are constantly 
annoyed with the unexpected and undesired response of 
the nerve-centres of individuals to some of the most com- 
monly prescribed drugs. This extraordinary susceptibility 
to certain drug poisons is almost always a limited affair, 
that is. limited to certain nerve-centres in that particular 
individual, so that one person's idiosyncrasy is against chlo- 
ral but not against morphia, or vice versa. What it is that 
weakens the resisting power of certain centres to certain 
poisons only we cannot tell, but it is quite conceivable that 
such a weakness may be set up by a permanent sensory 



FUNCTIONAL NER VOL'S DiSEASES. 237 

irritation which may cause a toxic influence to be as opera- 
tive in causing a convulsion as a single indigestible article 
in the stomach has been known to develop the first attack 
of uraemic asthma. 

If insight into the origin of functional nervous diseases, 
therefore, is not to be expected from an investigation of 
their structural relations, in what direction are we to look 
for more satisfactory indications of their true nature, and 
thereby of their treatment ? In reply, we would begin by 
a single clinical illustration : 

A lady consulted me for very pronounced and severe 
symptoms of Graves' Disease, except that she had only 
moderate enlargement of the thyroid and but slight exoph- 
thalmos. She had, however, an exceedingly rapid pulse, 
tumultuous heart action, great loss of flesh, and persistent 
diarrhoea. She did not improve under a varied medication, 
but at once began, literally, to get well when she was put on 
an exclusive diet of fermented milk. After some months, 
she tired of the milk and resumed ordinary diet. Her old 
symptoms progressively returned. She took up the milk 
diet again, and at once greatly improved again. She then 
left off the milk, and though the symptoms once more re- 
curred with great severity, yet she could not be persuaded 
to resume the milk until a short time before her death, 
Now, it is difficult to resist the inference that both the de- 
velopment of Graves' disease in her case was, for a time at 
least, a matter of diet — but what does that fact imply ? 

There may be (I only say there may be) an explanation 
in the view that a poison was generated in her intestines 
during her maldigestion which acted as a vaso- motor 
paralyzer when absorbed into the blood. This poison may 
have been exceptionally active in her case either from its 
specific nature, or because her liver, owing to some derange- 
ment, did not destroy the absorbed poison as it should, or 
lastly, because her kidneys did not eliminate itas they should. 
Room for speculation there certainly is, but the fact still 
remains — diet had more control over her disease than any- 
thing else had. Here a recent observation from a series of 
experiments by Charrin and Roger may have some bearing. 



238 W. H. THOMSON. 

They found that the urine of a man fed upon an exclusively 
milk diet lost the toxic properties of normal urine when 
injected into rabbits, guinea pigs, and dogs indifferently in 
great the proportion of one to ten. (La Semaine Medicale, 
1888.) 

That decompositions are constantly occuring in our di- 
gestive laboratory in the healthiest state of the body, which 
yet are accompanied by the formation of definite and viru- 
lent poisons, is one of the most important discoveries of 
modern science. As Dr. Lannder Brunton remarks, 1 "We 
may now indeed regard alkaloids as products of albumi- 
nous decomposition, whether their albuminous precursor be 
contained in the cells of plants and altered during the pro- 
cess of growth, or whether the albuminous substances 
undergo decomposition outside or inside the animal body, 
or by processes of digestion. Thus the poisonous alkaloid 
muscarine, which had only been known as obtainable from 
a plant, the Agaricus muscarms, has been discovered by 
Brieger to be a product of the decomposition of fish. A 
considerable production of alkaloids takes place in the 
intestines, both when the digestive processes are normal 
and more especially when they are disordered ; at the same 
time, alkaloids are being formed in the muscles and possibly 
in other tissues, Were all the alkaloids to be retained in the 
body, poisoning would undoubtedly ensue, and Bouchard 
considers that the alkaloid formed in the intestine of a 
healthy man in twenty-four hours would be sufficient to kill 
him if they were all absorbed and excretion stopped." 
That these formations of alkaloidal poisons are in many 
instances due to the activity of specific bacteria is also de- 
monstrated. It is thus that indol is produced out of the pro- 
ducts of pancreatic digestion, and then sent to the kidneys 
to excrete as indican, as shown by Brieger, The same has 
demonstrated by Thudichum to be the source of the coloring 
principles of the urine, first formed in the intestine and 
then sent to the kidneys for excretion. (Lancet, Dec. 1889.) 
It has even been proposed to use these facts to determine 

1 Pharm and Tox., p. ioo, 89. 






FUNCTIONAL NERVOUS DISEASES. 239 

the degree in which the kidneys have been damaged in 
chronic Bright's disease, by noting how much less toxic 
Bright's disease urine is than normal urine, as an indication 
of the failing power of the kidneys to eliminate the poisons 
that come to it from the great digestive laboratory. Thus, 
according to Bouchard's modification of the original ratio 
of Feltz and Ritter, the urine of a healthy person injected 
into a rabbit's vein kills in the proportion of 50 grms, per 
kilogram of weight of the rabbit's body. But that of Bright's 
disease subjects is tolerated in much larger doses, Dieula- 
foy mentions a rabbit of 2 kilograms weight for which the 
toxic dose of healthy urine would be 100 grms. but which 
showed no discomfort until 260 grms. of the urine of a 
patient with Bright's disease had been injected, and even 
then recovered (" Lancet," June 4, 1887.) 

The constant production during healthy life of these 
animal poisons as they can be guaged by their elimination 
in the urine, is shown even by their periodic variability. 
Thus Bouchard, (" sur la variations de la toxiiite urinaire 
pendant la reille et pendant la sommeil." Gaz. Hebdom- 
adaire," April, 1886.) shows that if the day be divided into 
three peroids of eight hours each, the proportional quantities 
of poison excreted are: asleep, 3; early wakening period, 
7; late waking period, 5. The urine after sleeping and 
waking hours also differs qualitatively as well as quantita- 
tively. The alkaloid of the urine of sleep is convulsive, 
that of the waking urine narcotic. Fasting increases the 
toxicity of the urine. Labor and increased respiration of 
fresh air greatly diminishes the toxicity. We would by such 
facts seem to have some clue to the nocturnal character of 
some cases of epilepsy, also of attacks of asthma, gout, etc., 
during the later hours of the night. But the chief interest 
of these discoveries lies in the illustration which they afford 
of the continued liability throughout life, of the nervous sys- 
tem to causes of the most serious functional derangements 
from the uninterrupted formation in all the processes of life 
of active functional poisons which would operate immediately 
were the means provided for their elimination or destruction 
to become disordered. 



24O W. H THOMSON. 

This subject, however is so extensive that we are pre- 
cluded by want of time to allude to more than a few illus- 
trative examples. Thus one of the most suggestive forma- 
tions of a poison in the body consists of the allied poisons 
choline, neurine and muscarine, the latter two being ex- 
tremely virulent. Now choline, which has been found by 
Brieger to be such a common product of putrefaction, has 
been found by numerous investigators (Boehm, Schoeff, 
H. Griers, Jahns, et a/.) very extensively in leguminous 
plants, as beans and lentils, in peanuts, cottonseed, hops, 
and therefore in beer, besides in various edible fungi. 
By a single substitution of a molecule of water choline 
is turned into neurine, a substance which has been 
stated by Liebrich ("Untersuch. uber Ptomaine," I., p. 32) 
to exist only in brain matter, but Prof. Schmidt (" Pharm. 
Rundschau," 1887, p. 266) has shown that when hydrochlo- 
ride of choline is allowed to stay in contact with blood for 
some time at a temperature 30-35 C. it is converted into 
neurine, while Wurz (" Bielstein's Org. Chem." p. 402) has 
shown how choline by treatment with an acid is converted 
into muscarine, the alkaloid found, as stated above, by 
Brieger in fish. In this connection the valuable researches 
of Knorr (" Pharm. Zeitung," p. 366) on the molecular 
constitution of morphine, are interesting, as he shows the 
very close relationship of the latter to choline, 2 

These facts at least demonstrate that we do not have to 
go far to find the explanation of every symptom of func- 
tional neuroses when the system is constantly producing 
the agents which would inevitably occasion them all with- 
out exception, according to the varying conditions of its 
functional activity. Headache, muscular languor, diarrhoea, 
depression of the heart or palpitation, depression of the 
spirits, and convulsions are among the toxic symptoms, and 
moreover, like our familiar drug poisons, these body-gene- 
rated alkaloids have their relative affinities for different 

* For an exhaustive account of this subject consult the able and scientific 
paper of Prof. F. B. Power and Jacob Cambier, of the University of Wiscotsin, 
on their "Isolation of Choline from the Bark of the Common Locust or False 
Acacia." Supplement "Scientific American," Mar. 15-22, 189c. 



FUNCTIONAL NERVOUS DISEASES. 24 1 

nerve-functions as special and as characteristic as any of 
the agents of our materia medica. In fact, so close is the 
resemblance that they have often given rise to disputes in 
medico-legal cases. Thus, in the celebrated Brandes-Krebs 
trial, two chemists obtained from the cadaver in addition to 
arsenic, an alkaloid which they pronounced to be coniine, 
but which Otto proved only to be closely analogous to 
coniine and also to nicotine. Brouardel and Bautney found in 
the body of a woman who died from eating a stuffed goose 
a body which gave the odor of coniine and the same re- 
actions of that poison with gold chloride and potassium 
iodide. In a criminal prosecution at Verona. Ciotta ob- 
tained from the exhumed but only slightly decomposed 
body, an alkaloid which he pronounced as identical with 
strychnine, until this identity was disproved by Selmi. So 
also, have morphine-like substances, others closely resem- 
bling atropine, others like digitalis, been found in similar 
toxical cases. (" Vaughan on Ptomaines and Leucomaines," 
p. no, sg.) 

Against this auto-infection or self-poisoning we seem to 
be protected in great part by the liver. It is fully demonstra- 
ted now that the liver possesses a two-fold power, to pre- 
vent poisons entering by the portal vein from passing into 
the general circulation, for it turns back some and de- 
stroys others. Some poisons, such as curare, are sent back 
in large part by the bile, but with others it either decomposes 
them altogether or renders them in large part innoccuos, for 
double the quantity of strychnia, veratria or morphia is 
required to kill an animal if injected into the portal vein 
as would be sufficient if injected into the jugular vein, while 
no less than three times the quantity of curare is requisite 
(Brunton op. lit.) The remainder seems to be sent to the 
kidneys for elimination. 

But a greater preservative still remains in the natural 
digestive secretions of the alimentary canal itself. In the 
case of the gastric juice this was shown long ago by De 
Haen, but the same fact holds true of the intestinal diges- 
tive juices that no better antiseptics can be found. This 
double function of the digestive secretions is too often over- 



242 W. H. THOMSON. 

looked, namely: that they not only digest but preserve. 
Any suspension or perversion of normal digestive secretion 
therefore, at once raises the danger of poisoning from the 
ready perversion of the contents of the raTral to undergo 
fermentation when the digestive juices are deficient. Often 
the resulting catarrh of the intestines from the local irrita- 
tion of such fermentation leads to the flux of summer diar- 
rhoea, which to a certain extent is therefore beneficial 
rather than harmful. But on the other hand, this danger of 
auto-infection is one of the commonest attendants of fever 
from the rapidity with which the fever process arrests all 
gland secretion, including the alimentary secretions, and no 
one who watches the symptoms of typhoid fever can fail to 
note how many of them resemble those of toxic infection. 
As we might expect, therefore, the urine has been found in 
fever, especially in typhoid, (Bouchard, Lepine, Guerin, 
Brunton) to be much more toxic than normal urine. Mr. 
A. P. Luff, Lecturer on Toxicology, St. Mary's Hospital, 
London, ("Brit. Med. Jour.," July 27, 1889) claims to have 
found a distinct alkaloid in typhoid fever and another in 
scarlet fever. 

Closely allied to the genesis of functional diseases are 
the problems connected with those varied morbid states of 
the blood to which the general term anaemia is given, and 
in this connection, we can only refer to the admirable lect- 
ures on the " Pathology of Pernicious Anaemia," by Dr. W. 
Hunter, which form the most important recent contribution 
to medicine by British investigators. (" Lancet," Sept. 22, 
29; Oct. 6, 1888.) After demonstrating that this is a specific 
disease on account of its showing a characteristic structural 
lesion, namely: the deposit of iron in the liver cells, he 
says: "In pernicious anaemia the seat of disintegration is 
chiefly the portal circulation, more especially that portion 
of it contained within the spleen and liver, and the destruc- 
tion is effected by the action of certain poisonous agents, 
probably of a cadaveric nature, absorbed from the intestinal 
tract." This hypothesis is rendered all the more probable 
by the febrile character of this affection which has always 
served with me to distingush this from other forms of seri- 



FUNC TIONAL NER VO US DISEA SES. 243 

ous anaemia with which it is often confounded. In later 
communications published in "The Practitioner," (see also 
" Lancet," Jan. ir, 1890) Dr. Hunter adduces still further 
confirmations of the view that pernicious anaemia is due to 
a haemolytic process induced by some ferment in the gastro- 
intestinal tract by observations on the excretion of patho- 
logical urobilin, of blood pigment, and of urine in this dis- 
ease. In a typical case which he examined, he draws 
attention to the exceedingly high color of the urine although 
the specific gravity remained low. Bile pigments were not 
the cause of this coloration, for spectroscopic examination 
showed it due to that form of pathological urobilin which 
MacMunn proved to be distinct from the urobilin of normal 
urine and to be formed by excessive elimination of bile 
into the intestine. Dr. Hunter then instituted an inquiry 
into the excretion of iron in the urine in health and in dis- 
ease, and he estimates the daily health average as from 3 to 
5 millegrammes. He found that the administration of iron 
by the mouth hardly, if at all, increased the amount of iron 
excreted. In one observation in health the iron excreted 
amounted to 5.65 mm., in one case of chlorosis to 1.71 mm., 
in another 1.96, and in a third 1.61, considerably lower than 
the average but consonant with the diminished richness of 
the blood in haemoglobin characteristic of this affection. 
But in the case of pernicious anaemia, the daily average of 
iron excreted for about three weeks in the urine amounted 
to the great figure 32.26 millegrammes. 

In the afebrile disease, chlorosis, on the other hand, many 
modern investigators ascribe the blood-change to absorp- 
tion of poisons from retained fecal accumulations. Sir 
Andrew Clark is such an advocate of this theory that he 
proposes to term chlorosis, fecal anaemia. There are some 
facts, however, in the -genesis of this disease which seem to 
me to lie back of the constipation of chlorotics, and which 
have an important bearing on functional nervous diseases 
as well. In not a few conditions we seem to have an illus- 
tration of a vicious circle of interacting causes of disorders 
of digestion, beginning with a reflex nervous irritation sus- 
pending or perverting the digestive secretions and also 



244 W - H - THOMSON. 

paralyzing the intestinal movements, while these effects in 
turn become causes of the formation and the retention of 
excrementitious matters, and thus of auto-infection. When 
I first entered on the practice of medicine I met a remark- 
able instance of the kind in consultation with two medical 
friends, who also called in the late Dr. White, of Buffalo, 
professor of obstetrics in the Bellevue Hospital Medical 
College, New York, The particulars of the case I pub- 
lished in the "Transactions of the New York State Medical 
Society," for the year 1867, p. 148. The patient, being a 
girl, aged seventeen, who, after a suppression of the menses, 
induced by a wetting in a cold shower, had first all the 
symptoms of intestinal obstruction with repeated fecal 
vomiting, but with no pain. By the administration of 
active purgatives some scanty movements would be ob- 
tained ; but though calomel (with jalap) was freely given, 
yet the dejecta were uniformly so white as to resemble lime 
plaster. (We now know that this absence of color in the 
faeces denoted suppression of the pancreatic as well as of 
the biliary reactions.) If purgatives were not given, the 
constipation would continue, soon to be followed by sterco- 
raceous vomiting. Ere long, however, a new train of 
symptoms set in. First, the urine was suddenly suppressed, 
and the death of the patient was daily anticipated ; but, 
instead of that, a profuse salivation occurred, amounting to 
about three pints daily, accompanied by a copious flow of 
tears, not caused by any emotion whatever. In fact, the 
mind of the patient was remarkably clear and composed 
from first to last, nor did she ever present a single symptom 
which could be properly termed hysterical. This combined 
salivation continued for about three days, and then ceased, 
whereupon the kidneys resumed their proper action for a 
few days more, and then stopped again, when immediately 
the saliva and the tears began to flow as freely as before. 
This alternation between these widely separated glands 
finally became a regular feature of the case, the change 
from one to the other sometimes occurring as often as on 
alternate days until death took place, in a little over two 
months from its first occurrence. Meanwhile the stereo- 



FUNCTIONAL NERVOUS DISEASES. 245 

raceous vomiting similarly alternated with small white 
alvine discharges, and the stomach refused to retain 
anything, so that life was maintained by nutritive ene- 
mata. 

Now, in this case, and in others similar to be found in 
medical literature, we have but an extreme illustration of 
the power of reflected irritation from pelvic nerves to 
derange both the whole series of the alimentary secretions 
and of the gastric intestinal movements, yet not differing 
except in degree from the common derangements of the 
early months of pregnancy. But just such influences may 
precede, and as I believe actually do precede, the develop- 
ment of the hysterical status. Why is it not a probable 
deduction that in the usually perverted and disordered 
intestinal digestion of hysterical patients we may have all 
the conditions needed for a veritable intoxication of the 
blood with functional poisons to which, rather than to an 
occult fault in nerve-centres, the symptoms of the disease 
are due ? Certainly, since I have treated hysteria with that 
conception in mind, by repeated purgation and the admin- 
istration of intestinal antiseptics, I have had, as I think, 
much better results than by dosing them with many of the 
old-fashioned antispasmodics. 

The same I can say of my treatment, in the main, of 
migraine. The frequent sallow complexion and the high- 
colored urine of these patients, on the subsidence of an 
attack of sick-headache, not to mention the early superven- 
tion of fermentative eructations in this affection, long ago 
led me to look upon the majority of these cases, not as 
instances of " nervous storms," but of cases of imperfect 
digestion ; and it is a question whether most of our reputed 
remedies for this form of headache do not act chiefly by 
virtue of their antiseptic properties. The fact that many of 
these cases present a history of marked hereditary predis- 
position rather favors the toxic theory, for both rheumatism 
and gout are equally characterized by heredity. The phe- 
nomenon of periodic explosion of the attacks, however, 
which this affection shows in common with some cases of 
epilepsy, is closely analogous with the occasional action of 



246 W. H. THOMSON. 

some functional poisons. For a long time I was inclined to 
be incredulous about the cumulative property of digitalis, 
simply because, like all incredulity, mine was based on 
nothing but the failure of my own experience to furnish a 
case, though I had prescribed digitalis largely. But one 
patient with phthisis, to whom I had given this drug in 
divided doses for about a week, banished my doubts ever 
after by a veritable explosion of the symptoms of that poison 
such as I will not soon forget. The same development is 
said to occur occasionally with strychnia. But the most 
marked illustration of this property of neurotics I had from 
a prescription, which I used, some ten years ago, quite 
extensively, in both hospital and private practice, for the 
reduction of temperature in phthisis, and which consisted of 
two drops of the tincture of aconite-root, with one drop each 
of the tincture of veratrum viride and of the fluid ext. gelse- 
min., given three times a day. It seemed to answer the 
indication very well during some two years' trial, but I was 
obliged to abandon it, owing to sudden and alarming symp- 
toms of collapse occurring in five cases, after some two 
weeks' or so administration, three of them in the Charity 
Hospital and two in the Roosevelt Hospital. After recov- 
ery from these prostrations, however, the temperature 
remained down for prolonged periods in each of the pa- 
tients, in no case less than two weeks and in one for three 
months. 

I had intended to speak fully on the bearing of these 
considerations on the treatment of epilepsy, but time fails 
me now, and I will have to defer that to another oppor- 
tunity. Of course, with such a great variety of afferent 
exciting causes to induce the attacks, one cannot claim that 
epilepsy can be ascribed chiefly to infection by functional 
poisons in more than in a certain proportion of cases. Yet 
that a great many epileptics cannot be relieved until this 
source of functional derangement is detected and remedied, 
I fully believe from results in treatment which in some 
instances have been too pronounced to admit of doubt^ 
Among other questions, I always ask whether a bad breath 
is noticed, either as preceding the attacks or as occurring 



FUNCTIONAL NERVOUS DISEASES. 2\J 

during them. This symptom I find to be quite common, 
while in other cases constipation or diarrhoea is so associ- 
ated, and not infrequently such clues have proved of the 
greatest value in directing the treatment. 

The course of medical progress has been aptly likened 
to a spiral ascent, opinion repeatedly coming round toward 
former positions, but each time above, rather than at the 
level of the older views. The doctrines of cellular pathol- 
ogy and the great increase in the knowledge of the struc- 
tural changes of disease, especially in the case of the heart, 
lungs, and kidneys, with their consequent aids to diagnosis, 
have displaced for years the humoral pathology of our 
predecessors. These advances have caused the stomach 
and bowels to lose much of the importance which they held 
in the minds of the old physicians as the chief centres of 
the processes both of life and of disease. Now, however, 
that chemistry is asserting her claims to be heard, as well 
as anatomy, the set of the current is once more in the old 
direction. It is curious, therefore, to find this tendency re- 
enforced even from the side of anatomy. It sounds 
strangely like a distant echo of the ancient teaching, that 
the origin of feelings, emotions, and moral characteristics 
is in the bowels, to find St. Paul, with his exhortation to 
put on " bowels of mercies," confirmed in a way by Dr. J. 
Bland Sutton, who says that " he is convinced that the 
spinal cord and brain of vertebrata have been evolved from 
what was originally a section of the alimentary canal ; in 
other words, the central nervous system is a modified piece 
of bowel" (!). 3 Dr. Gaskell also comes to the same conclu- 
sion by a different course of research, and states that " the 
tube which primarily represents the central nervous system 
in the vertebrate embryo must be regarded as a disused 
segment of the primitive alimentary canal." 4 

3 Brain, vol. x., p. 432. 

4 Ibid., vol. xi., p. 336. 



geriscopne. 



By Drs. PETERSON, PRITCHARD, PICK, FISKE-BRYSON, LESZYNSKY 
AND PECKHAM. 



EXCEBPTS FROM GERMAN JOURNALS. 

By FREDERICK PETERSON. 

TUMORS IN THE REGION OF THE CORPORA QUADRI- 
GEMINA. 

Prof. H. Nothnagel writes upon this subject in the 
Wiener med. Presse, 1889, No. 3, basing his study upon ten 
cases collected by Bernhardt and four of his own. The first 
case described is as follows : 

A boy, aged fifteen, fell from a tree, in 1885, and was 
unconscious and confined to bed for a short time. After a 
little he began to be unsteady in his gait and often fell to 
the floor. In the winter of 1 886-1 887 he suffered from 
severe headaches, pain in the eyes, nausea, and vomiting ; 
later, optic atrophy, complete amaurosis, dizziness, and 
some deafness, the last due to chronic catarrh of the middle 
ear. Two symptoms especially were of value for 
diagnosis : first, a well-marked ataxia (Duchenne's titubation 
cerebelleuse); and secondly, the rigidity of the bulbi, whose 
movements were limited, particularly upward and to the 
left, more on the left than on the right side (there was 
paresis of the third and sixth nerves). The pupils were 
equal, their reaction sluggish. The diagnosis of tumor of 
the corpora quadrigemina with consecutive hydrocephalus 
was corroborated by autopsy. It was a papillary epithelial 
tumor, springing probably from the choroid plexus. 

In the ten cases collected by Bernhardt was also one of 
his own, and since then he had observed three others. 

Sensibility to light and vision, the reflex centre for the 
iris and the movements of the eye, some relation to general 
sensibility, blood pressure, vasomotor nerves, or corporeal 
equilibrium, all these had been at various times by various 
authors, located in the quadrigeminal bodies. Clinical 
features were often complicated by hydrocephalus, effects 
on distant or neighboring parts, etc. Hence, the author 
lays stress upon ataxia and paralysis of the ocular nerves 
as the chief factors in making a diagnosis. In almost all 
the cases there was the uncertain staggering gait. In three 
of his cases, all due to trauma, ataxia was the first symptom. 



PERISCOPE. 249 

This could not be due to hydrocephalus, because the hydro- 
cephalus only made itself evident sometime after the devel- 
opment of the ataxia. Pressure upon the cerebellum, or 
upon the crura cerebelli ad pontem did not seem to be a 
sufficient cause for the ataxia, since there were cases where 
the cerebellum was not affected, and yet ataxia was the 
initial symptom. This symptom seemed chiefly due to a 
disturbed function in the posterior quadrigeminal pair, since 
Gowers had described a case without ataxia in which only 
the anterior pair were affected. The ataxia is precisely like 
every other cerebral ataxia, such as that of drunkenness, 
and hence is not pathognomonic of quadrigeminal tumors. 

The disturbances of vision, blindness, etc., depends 
chiefly upon choked discs, neuritis, optic atrophy, and 
hence nothing can be deduced irom them as regards any 
direct relation to these bodies. 

Kohts observed a boy with a posterior quadrigeminal 
tumor, who first presented a staggering gait, and only 
shortly before death slight visual disturbance. Paralysis of 
the ocular nerves was observed by Prof. Xothnagel in all 
of his cases ; the bulbi were more or less immovable. The 
division of the paralysis was unequal, sometimes one part 
being more affected than another, or one eye more than 
another. In most of the cases, besides the third nerve, the 
fourth and sixth were also included in the injury. Such 
paralysis appearing in association with ataxia must lead 
one to think of a quadrigeminal tumor, since the nuclei are 
so closely aggregated in this region. 

In one of the author's cases there was a tumor the size 
of a hazel nut, limited to the quadrigeminal bodies, includ- 
ing little injury to parts about the aqueduct of Sylvius, and 
leaving all other parts unaffected. This patient had no 
paralysis of ocular muscle, and presented a nystagmus only 
after several years. The nystagmus was probably due to 
slight irritation of the nuclei. 

The localization of a tumor in the quadrigeminal region 
is to be based upon a combination of cerebral ataxia and 
simultaneous paralysis of ocular muscles on both sides in 
varying number and intensity. Hydrocephalus may also 
be associated. The diagnosis would remain the same even 
if, after the development of the above-named symptom, a 
hemiparesis, or hemianaesthesia should also be added, since 
the latter would merely be symptoms of pressure upon the 
pedunculus. 



250 PERISCOPE. 

A CASE OF TUMOR OF THE PINEAL GLAND. 

In the Neurologisches Centralblatt, May 15, 1889, Dr. 
Eugen Kny describes a case of tumor limited to the pineal 
gland, adding a ninth to the seven collected by Schulz 
(same periodical, 1886, No. 19), and the one reported by 
Daly ("Brain," July, 1887). The clinical history is briefly 
as follows : 

J. H., aged thfrty-two, suddenly began, in the spring of 
1881, to have sharp pain in the occipital region, spreading 
in a year over both parietal and frontal regions. Since 
July, 1882, continual tinnitus aurium, and painful throbbing 
in the head. Later vertigo, blackness before the eyes, gen- 
eral tremor and periods of dimness of consciousnss ; gradu- 
ally diminished vision. Feb. 1, 1883, choked discs, complete 
blindness in the right eye, light perceptible in the left. 

August, 1884 : Epileptiform convulsions. Dribbling of 
urine. 

Nov., 1884: Nystagmus. Slowness of speech. Occipital 
pain continually. 

May, 1885 : Gradual weakening of the intelligence. 

Nov , 1885 : Strabismus divergens. Great tendency to 
fall backwards. No paresis. Anosmia. Cutaneous sensi- 
bility normal. In the last months of his life, dementia, 
soiling and wetting the bed. Wide rigid pupils. Bulbi 
peculiarly rigid, protruding, diverging. Epileptiform at- 
tacks. 

Aug. 28, 1886: Death, with sudden sopor and rising of 
temperature to over 40 C. 

Autopsy by von Recklinghausen: A lobular round-celled 
sarcoma of the pineal gland the size of a walnut. The cor- 
pora quadrigemina were not connected with the tumor, but 
flattened in front and pressed backwards. 

PATHOLOGICAL FINDINGS IN A CASE OF TRAUMATIC 
NEUROSIS. 

Drs. Sperling and Kronthal (Neurolog. Centralb., June 
1-15, 1889) give the clinical history and result of autopsy 
in a case of traumatic neurosis, which are condensed briefly 
as follows : 

A man, aged forty-two, was so badly shaken up in a 
railway collision, in 1884, that he lost consciousness for a 
short time. A physician examined him and found bruises 
over his temple and abdomen. The patient complained 
only of a general feeling of fatigue. Within a few weeks a 
variety of inconstant symptoms appeared : there was psychic 
depression, apathy, irritability. He was easily startled by 
noises of passing trains, which would cause precordial pain 



PERISCOPE. 25I 

and a choking sensation. His sleep was harassed by fright- 
ful dreams. He had frontal headache, extending back to 
the neck and at times down the spine, formication in the 
hands or feet, ringing in the ears and flashes before the 
eyes. He had such a feeling of weakness that the slightest 
attempt at work caused general tremor. His gait was wide 
and so uncertain as to require the use of a cane. Muscula- 
ture strong, and no disturbance of sensibility except the 
constant presence of painful points over the supraorbital 
regions. Knee-jerks and other reflexes considerably dimin- 
ished. Sexual impotence. Palpitation. 

A suit for damages was lost, physicians testifying that 
there were no objective symptoms, but probable simulation. 
Later, however, upon the testimony of Prof. Eulenburg and 
Dr. Sperling that the patient was entirely incapable of 
work, the decision was changed. 

Hypnotism had a surprisingly good effect upon the 
patient. But January 27, 1889, patient died from cardiac and 
pulmonary disease. 

The railway collision was not severe. No other person 
was injured, and none of the cars demolished. 

The autopsy revealed a great degree of sclerosis, with 
here and there hyaline and fatty degeneration of the entire 
arterial system, but particularly in the cerebro-spinal ves- 
sels. There was a peculiar degeneration of the trunk of 
the sympathicus. In the spinal cord were scattered points 
of slight degeneration in all parts of the white substance, 
degeneration of the ganglia cells in a small part of the 
lower dorsal region, and a small haemorrhage in the mid- 
dorsal region. 

THE DIAGNOSTIC VALUE OF INCREASED KEEE-JERK AND 
ANKLE CLONUS. 

Dr. T. Ziehen (Corresp. Blatter des allg. arztl. Vereins 
von Thuringen, No. 1, 1889) puts in the form of a series of 
valuable clinical rules his experience with these reflexes: 

Unilateral' exaggeration of the knee-jerk is always sig- 
nificant of disease. 

Bilateral exaggeration of the knee-jerk is only signifi- 
cant when ankle clonus co-exists. 

Ankle clonus may be physiological in children ; in 
adults it is pathological. 

Ankle clonus and exaggerated knee-jerk occur in sixty 
per cent, of cases of epilepsy, while the plantar reflex is 
often strikingly weak. 

The combination of diminished plantar reflex with in- 



252 PERISCOPE. 

creased knee-jerks indicates functional, and not organic, 
disease. 

Ankle clonus is found in twenty per cent, of cases of 
hysteria in general, but in a much higher per cent, of cases 
with hystero-epilepsy, paralyses, anaesthesia, etc. 

Ankle clonus is rare in paralysis agitans, very marked 
in paramyoclonus multiplex ; exists in twenty to thirty per 
cent, of cases of neurasthenia ; in some fifty per cent, of 
the psychoses ; in tetanus, but not in tetany. 

Exaggerated knee-jerks were found in 17.2 per cent, of 
criminals by Marro and Tombroso. 

Exaggeration of deep reflexes in spastic spinal paralysis 
and amyotrophic lateral sclerosis differentiates decisively 
progressive muscular atrophy and neuritis, where they are 
absent. 

Ankle clonus has the same relation to degeneration of 
the lateral columns of the cord as Westphal's symptom has 
to that of the posterior columns. 

In ordinary apoplexy, with the loss of consciousness a 
primary foot clonus is observed, which shortly disappears. 
But if in two weeks to two months a secondary ankle 
clonus appears in the paralyzed leg, it means secondary 
degeneration of the lateral columns and leads to the certain 
anticipation of a permanent active hemicontracture. 

Ankle clonus without other especial symptom leads one 
to suspect epilepsy or neurasthenia. 

Ankle clonus with hemianesthesia indicates hysteria ; 
with intention-tremor, multiple sclerosis ; with atrophy, 
amyotrophic lateral sclerosis ; with spastic-paretic gait, 
spastic spinal paralysis or progressive paralysis ; with 
anaesthesia of legs and paraplegia, dorsal or cervical mye- 
litis. 

Unilateral ankle clonus in hemiplegia or monoplegia 
indicates a cerebral lesion, and excludes almost always a 
spinal affection. 

THEORY OF THE ORIGIN OF THE TRAUMATIC NEUROSES. 

Th. Meynert discusses this subject in the Wiener klin. 
Woch., 1889, Xo. 24-26. He does not think there is any 
disturbance of the cortex, but that the functional disorder 
has its seat in the conducting tracts of the forebrain. The 
organic unilateral paralyses and anaesthesias are, as taught 
by Charcot, due to disturbances in the region of the arte- 
riae lenticulo-opticae. Functional or traumatic hemiplegia 
is caused by nutritive disturbances in the region of the 
arteria chorioidea, which, according to Heubner and Duret, 



PERISCOPE. 253 

nourishes the posterior segment of the internal capsule, the 
walls of the ventricles and their ganglia. 

Kolisko's injection-experiments, not yet published, show 
that the nutritive region ot the arteria chorioidea includes : 
the optic tract, internal capsule, wall of the descending 
horn and the cornu ammonis (smell centre, Zuckerkandl). 
Thus a nutritive disturbance of this vessel explains cere- 
bral hemianaesthesia with unilateral blindness, anosmia and 
motor paralysis. The fact that the face and tongue are 
not affected in the functional disorders is explained by the 
position of their nerve tracts in the most anterior part of 
the posterior portion of the internal capsule, more on the 
border between the posterior and anterior limbs. 

The anterior portion of the internal capsule receives its 
nutritive branches from vessels coming through the lamina 
perforata 

The arteria chorioidea seems to have a predilection for 
functional disturbances, because it is the smallest branch of 
the basal vessels, and because it has no anastomoses with 
other basal arteries ; hence, a vicarious distention or col- 
lateral overflow is not possible in its area when, for instance, 
there is a general spastic contraction of the circle of Willis. 
And in functional paralyses we are mostly concerned with 
spastic, vasomotor disturbances, such as irritation of the 
subcortical emotional centres and transfer of the irritation 
to the circle of Willis through the sympathetic. 
EXPERIMENTAL OBSERVATIONS OF THE RELATION OF 
THE MOTOR GANGLION CELLS OF THE CORD TO THE 
PERIPHERAL NERVES. 

Dr. Alb. von Sass, of Dorsat, contributes a paper upon 
the above subject to Virchow's Arch., vol. cxvi., part 2. 

Prevost and David found in atrophy of the muscles of 
the hand atrophy of the roots of the seventh and eighth 
cervical nerves with atrophy of the anterior horn (especi- 
ally affecting the cells of the lateral group) two to three 
cm. in length. 

Sahli in a similar case found atrophy of the anterior 
horn at the level of the fourth to the seventh cervical 
nerves, particularly in the postero-external region. 

Kahler and Pick examined the cord of a person whose 
arm had been amputated six years before, finding partial 
atrophy of the ganglion cells of the external group at the 
level of the fifth and sixth cervical nerves ; while Hayem 
and Gilbert in a similar case found the motor cells in the 
whole cervical region affected, but more especially at the 
level of the seventh and eighth cervical and first dorsal 
segment. 



254 PERISCOPE. 

Kahler and Pick located the centre for the calf muscles 
in the fourth and fifth lumbar segments ; for the thigh, in 
the second to the sixth, but chiefly in the fifth and sixth 
(the middle group of cells). 

Schultze placed the motor nuclei of the sciatic nerve in 
the lower portion of the lumbar enlargement, but the cen- 
tres for the tibialis anticus and for the crural and obturator 
nerves higher. 

Gudden, Mayser, Forel and others have induced atrophy 
of the nerve nuclei, experimentally, by section or removal 
of portions of peripheral nerves ; and von Sass, making use 
of this method, has made the following localizations in the 
cord : 

Median nerve — eighth and parts of the sixth and seventh 
cervical segments. 

Radial nerve — Parts of the fifth and eighth and the 
whole seventh cervical segments. 

Ulnar nerve — Upper half of the first dorsal, and the 
lowest and uppermost third of the eighth cervical segment. 
Sciatic nerve — Lower half of the lumbar enlargement, 
and most strongly towards its middle. 

The origin of the radial nerve was highest, generally 
speaking; that of the median, next; and of the ulnar, 
next ; so that the muscles occupying the highest levels on 
the extremities seem to be represented in the highest levels 
of the cord. 

HEMIATROPHY OF THE BRAIN. 

At a meeting of the Budapest Medical Society, May II, 
1889 (Centralb. f. Xervenheilk., June 15, 1889), Jacob Salgo 
presented a brain showing hemiatrophy. A young man of 
nineteen years, idiotic, had suffered from earliest childhood 
from epilepsy and left hemiplegia. The right hemisphere 
was hardly half as large as the left, and the convolutions, 
particularly in the occipital region, were as thin as paper. 
The change was least marked in the central gyri. The 
right basal ganglia were atrophied. The atrophy ceased 
at the pons ; spinal cord normal. 

Jendrassik remarked upon the case that the brain showed 
the lesion of a cortical hemiplegia. According to his obser- 
vations upon such atrophic convolutions, the connective- 
tissue is increased and the nerve-fibres disappear. This 
pathological condition usually follows an acute infectious 
disease. 



PERISCOPE. 

THE PSYCHIC AND SOMATIC DEGENERATION OF 
CRIMINALS. 



255 



Prof. Kirn contributes to the "Centralb. f. Nervenheil- 
kunde," August 1, 1889, an interesting paper on criminal 
anthropology. He presents the views of the Italian school 
regarding the mental and physical abnormalities found in 
habitual criminals. 

Among the primary stigmata degetierationis are those of 
the skull, such as microcephaly, makrocephaly, asymmetry, 
clinocephaly, acro-oxy-cephaly, flat-head, and plagio- 
cephaly. 

Next in order to cranial changes are those of the face : 
the bird-face of the microcephalus, flattening of the upper 
part of the face in oxycephlus, deflection or flattening of 
the nose, protrusion of the superciliary ridges, asymmetry 
of the orbits, inequality of the position of the teeth, malfor- 
mation of the lips and palate, progaenia, and finally the 
numerous abnormalities of the ear. 

The rest of the body may present peculiarities such as 
dwarfishness, giant growth, asymmetry of the two halves 
of the thorax, club-foot and club-hand, and various anoma- 
lies of the sexual organs. 

Among certain common functional disturbances are 
diminution in sensibility, particularly analgesia, color- 
blindness, lack of power to blush, left-handedness, and 
abnormal sexual instinct. 

To the series of psychic anomalies belong weak intel- 
lect, lack of uniformity in mental development, a want of 
sufficient comprehension of the immorality of crime and 
consequent impossibility of remorse or improvement, emo- 
tional inconstancy, and a tendency from childhood to evil 
and wickedness. From these facts several important con- 
clusions have been drawn : 

1. Congenital criminality is identical with moral insan- 
ity. Both conditions exhibit the same physical defects and 
malformations, and the same mental deviations ; and both 
are usually congenital, becoming worse at puberty. 

2. Epileptics are nearly related to criminals, for analo- 
gous bodily and mental stigmata are common to both. 

Regarding the above teachings of Lombroso and his 
followers Prof. Kirn expresses his own beliefs as the result 
of his experience. 

He says the symptoms of somatic and psychic degenera- 
tion that have been described, although found in a large 
number of habitual criminals, are not by any means gener- 
ally present, and have therefore only a relative value. 



256 PERISCOPE. 

But experience in court and prison certainly shows that 
many deeds punished as crimes are committed under the 
influence of certain anomalies of brain function. The most 
important of these is weak-mindedness, which may be either, 
congenital or acquired. In the former case there is defect 
or malformation of the brain ; in the latter there is psychic 
degeneration due to alcoholism, epilepsy, injuries to the 
head, or chronic cerebral disease. There is a pathological 
inferiority or perversity ; some habitual criminals remain 
on a low plane of mental development, others exhibit a 
pathological growth. 

Prof. Kirn thinks that great weight should be laid upon 
cranial anomalies, since they are i 1 fact sometimes observed 
in habitual criminals. But there is no characteristic defect 
or shape of the skull that may be regarded as pathog- 
nomonic. 

Extensive craniometrical study has shown that there is 
in many of this class a tendency to abnormally small, and 
and in some to abnormally large, skulls ; but from this one 
is permitted to conclude only that a certain disposition 
exists in a number of criminals to morbid cranial and 
encephalic development. 

The structural anomalies thus far described, in the 
brains of criminals, are too few and not sufficiently cor- 
roborated to allow decided conclusions to be drawn from 
them. 

As regards the psychic symptom-complex, no uniform 
criminal type can be portrayed, but only various mental 
anomalies which exist in widely differing combinations in 
this class. 

He does not believe in the indentification of congenital 
criminality and moral insanity. The latter is not an ince- 
pendent disease, but only a symptom-complex, sometimes 
congenital in connection with other signs of defective 
development, sometimes acquired in conjunction with epi- 
leptic, paralytic, alcoholic and traumatic psychoses. Moral 
insanity, which may be observed in the most heterogeneous 
psychoses, may under conditions also make its appearance 
in the criminal nature. In opposition to the views of the 
Italian school, he thinks there is a total want of analogy 
between the epileptic neurosis and criminality. 

He finally concludes that an anthropological criminal 
type has decidedly no existence, but that there are to be 
found in prisons not a few individuals who present marked 
somatic defects and malformations, defective mental devel- 
opment, or psychic degeneration due to disease. 






PERISCOPE. 257 

AN INSTRUMENT FOR THE PERCEPTION OF LIGHT THROUGH 
THE SENSES OF TEMPERATURE AND POSITION, 

Dr. Noischewski presented to the Neurological Section 
of the Society of Russian Physicians, in January, 1889, an 
instrument which he calls the electrophthalmcyclop. It 
It consists of a small camera obscura, whose posterior wall 
is composed of three layers. The first is of fine metallic 
gauze, the second a closely approximated plate of selenium, 
and the last a brush-like arrangement of gold wires which 
are to come in contact with the skin. This veritable cyclop 
is applied to the middle of the forehead, and the light-rays 
falling into the apparatus are metamorphosed into a thermo- 
electric current, which is at once perceived by the glabellar 
nerve filaments, for the forehead has the senses of temper- 
ature and position particularly well developed. 

The inventor draws the following conclusions from his 
experiments with the instrument : 

The presence of a light-giving or of an illuminated 
object is manifested in the perceptive field as a sensation of 
warmth. 

A light object on a dark background is perceived as a 
peripherally warm sensation, with a sensationless centre. 

The degree of the sensation of warmth increases with 
the approach of the illuminating object, and vice versa. A 
movement of the feeling of warmth toward the right shows 
that the light has moved to the left, vice versa. 

If the warm area moves downwards, the illuminating 
object is moving upwards, and and vice versa. 

Hence the blind will be able to see light through the 
mediation of tactile sensibility. It is possible for them by 
means of this apparatus to perceive the presence of a light 
object, its position and its movements from side to side, up 
or down or nearer and farther away. — Centralb. f. Nerven- 
heilk., March, 1889. F - p < 



EXCERPTS FROM THE RUSSIAN. 

By DRS. PRITCHARD AND PICK. 

ON THE PHENOMENA APPEARING IN ANIMALS AFTER 
SECTION OF THE POSTERIOR COLUMNS OF THE SPINAL 
CORD, AND THE RELATION OF THE LATTER TO THE 
EQUILIBRIUM OF THE BODY. 

Prof. W. Bechterew (Wjestnik psichiatrii i nevropato- 
logii, 1889, vii., 1). The writer reports upon a series of 
experiments on doves, rabbits, and dogs, in which he sev- 



258 PERISCOPE. 

ered the posterior columns of the spinal cord. The section 
was made at the cervical portion, preferably in its upper 
portion. In a few experiments on dogs the section was 
confined solely to the columns of Goll ; in some the nuclei 
funic, grac. were only severed. Observation of the animals 
extended over a period of from some days to several months. 
The extent of the experimental procedure was controlled 
by postmortem and sometimes by microscopic exami- 
nation. 

At the moment of severing the posterior columns and 
immediately after, the animals show reflex movements of 
general unquiet ; yet these soon disappear, and then one 
observes, as a constant effect of the operation, disturbances 
of movement, which may be interpreted as disturbances of 
equilibrium. Neither paralysis nor paresis of the extremi- 
ties makes its appearance ; the animals retain their capa- 
bility of locomotion ; they can walk, stand, run ; co-ordina- 
tion of single movements remains uninfluenced : yet, in 
standing as well as in running, a remarkable insecurity is 
observed ; the animals tumble either forward or backward, 
or to either side. The flight of the doves operated upon is 
slow and difficult, and their bodies assume then a peculiar 
shape ; the jumps of the rabbits operated upon are irregular ; 
the dogs walk with their legs spread far apart, and their 
bodies sway from side to side. Blindfolding the eyes 
causes in all cases a greater prominence of these phenomena. 
If the animals remain alive a longer time, then a gradual 
decrease and sometimes, after several weeks, complete 
disappearance of the disturbances could be seen. 

As to the sensibility, the writer found it in no case to be 
reduced ; the muscular sense of the extremities was also 
not disturbed. On the contrary, anaesthesia of the fore- 
paws, together with loss of the muscular sense and disturb- 
ance of co-ordination, could be seen, in case the section 
was made at the height of the fifth to the sixth cervical 
vertebrae. 

In some cases the writer observed, in his animals experi- 
mented on, long -continuing hyperaesthesia, and indeed 
when section was made at the place of lesion it revealed 
inflammatory changes of the gray substance. The above- 
described disturbances of equilibrium made their appearance 
in the same way in dogs, in which not the entire column, 
but that of Goll was severed or the nuclei funic, grac. 
injured. 

The writer concludes from his experiments that the 
posterior columns are a path of conduction, which inter- 



PERISCOPE. 259 

ruption causes a disturbance of the equilibrium, with reten- 
tion of sensibility. 

A CASE OF SEMI-LATERAL FACIAL ATROPHY. 

L. Blumenau (Wjestnik psichiatrii i nevropatologii, 1889, 
vii., 1). A factory operative, fifty years of age, presented 
distinct atrophy of the right lower half of the face ; the 
cheek was here fallen in, the skin wrinkled, the lower lip 
thin, and the nostril narrower than on the opposite side. 
The atrophy also extended to the right half of the tongue, 
the soft palate, and the maxillary bone. His moustache 
only grew upon the left side ; the right side of the upper 
lip was completely hairless. The frontal region of the face 
was not affected. The sensibility of the skin, electric ex- 
citability, and peripheric temperature were normal on both 
sides of the face, 

The development of the morbid process began in his 
sixteenth year ; the patient observed then a whitish spot 
upon the upper lip. In his course of five years the atrophy 
reached its present extent, and since, then has remained 
without change. No circumstance could be found in his 
history to which one might attribute aetiological importance. 

COMPRESSION OF THE SPINAL CORD IN CONSEQUENCE OF 
FRACTURE OF THE SECOND DORSAL VERTEBRA. 

J. Anfimov (Wjestnik psichiatrii i nevropatologii, 1889, 
ii.). A man, thirty-four years of age, and up to that time 
in good health, employed upon a street-railroad, July 28, 
1888, was run over by a droschky, by which he got a vio- 
lent blow between the shoulders ; he fell prostrate and was 
thrown to one side. He did not lose consciousness and was 
able to raise himself and walk home, about fifteen kilom. 
away, where, about two to three hours afterward, sudden 
and complete paralysis of the lower extremities made its 
appearance. He was brought at once into the surgical 
clinic, where, besides complete paraplegia, inferior, paralysis 
of the bladder and rectum was diagnosed. Loss of sensi- 
bility over the entire body below the second rib was also 
remarked; temperature 37°C, pulse 48 in 1 ; painfulness to 
pressure of the cervical vertebrae. The next day an attack 
of asphyxia appeared, which was removed by artificial res- 
piration and injection of ammonia ; in the days following, 
phenomena of fever and decubitus. September 13th he was 
received into Prof. Mierzejewski's clinic in the following 
condition : 



26o PERISCOPE. 

Complete loss of cutaneous sensibility and of the muscu- 
lar sense over the entire body below the second rib and the 
upper dorsal vertebrae ; complete flaccid paraplegia inferior ; 
paralysis vesicae et recti ; complete absence of the tendon 
and skin reflexes of the lower extremities and trunk ; loss 
of the mechanical muscle; excitability and great reduction 
of the electric ; paralysis of the intercostal muscles and 
difficult respiration, chiefly affecting the diaphragm and the 
cervical muscles ; the movements of the head, upper ex- 
tremities, and further the consciousness and speech undis- 
turbed ; extensive decubitus in several spots, with gradual 
aggravation of the general condition and increase of the 
dyspnoea. Death occurred September 18th. Two days 
before, somnolence had added itself, together with acceler- 
ation of the pulse and high temperature, to the list of 
symptoms. 

Post-mortem examination revealed an oblique fracture 
of the second dorsal vertebra, with splintering of the bone, 
dislocation of the cartilage, and haemorrhage in its surround- 
ings. Corresponding to this place, there was found on the 
spinal cord, at the place between the cervical and the dorsal 
portions, a focus of softening, about one inch in length, in 
the whole breadth of the substance of the spinal cord. The 
softened place was reddishly colored; the dura mater in the 
neighborhood of the fractured vertebrae was thickened, 
hyperaemic, and adherent to a splinter of bone, which had 
been broken off. Below the softened place the appearance 
of the cord was normal. Microscopic investigation of the 
same revealed ascending and descending degeneration ; 
otherwise the tissue of the cord, even in distant regions — 
as, for example, from the lumbar enlargement — seemed 
dull, yet without distinct pathological changes. 

In considering the case, the writer calls attention to the 
difficulty of explaining the absence of "the tendon-skin 
reflexes in compression of the cord. 

A similar case was published, a short time ago, by 
Leyden and Jurgens (Berliner klin. Wochenschr., 18S8, 
Nos. 22 .and 24). In this case they would ascribe the ab- 
sence to the trauma being so violent as to cause an irritation 
of the cord and subsequent inhibition of the reflexes. 

P. & P. 

ERB'S PARALYSIS. 

The "Lancet" (March 1, 1890) records two cases that 
were exhibited before the Medical Society of London. The 
first was a man, thirty -one years old, who fell down-stairs, 
after drinking too much, and struck the point of the shoul- 



PERISCOPE. 26l 

der, causing inability to use the joint. The deltoid, supra- 
spinatus, infra-spinatus, pectoralis major (slightly), triceps, 
brachialis anticus, and supinator longus were affected, react- 
ing only slightly to faradism, the deltoid not at all. The 
faradic current was slowly bringing about a cure. 

The second case, a man of thirty-seven, was pitched 
from a cab, falling on the left shoulder and side of the head, 
stretching and straining the neck. He gradually lost the 
use of the arm. About the shoulder there was some anaes- 
thesia at first. The biceps, coraco-brachialis, brachialis 
anticus, deltoid, and supra-spinatus were completely para- 
lyzed. To strong faradism there 'was no reaction, the 
muscles giving the reaction of degeneration. A stretching 
of the brachial plexus is the cause of nearly all such paral- 
yses, this stretching corresponding to a lesion of the fifth 
and sixth cervical nerves before joining the plexus. In the 
monkey, paralysis of the biceps, supinator longus, and 
deltoid follows the division of these nerves. 

A woman, falling asleep with the neck resting against 
the edge of the table, found herself in this same unhappy 
plight on awaking. The same thing might happen in in- 
fantile paralysis ; without anaesthesia, however, the lesion 
being situated in the anterior horns. 

In answer to questions, Dr. Beevor, who exhibited the 
last case, said there had been no pupillary phenomena, 
which could only occur if the second dorsal nerve was also 
affected. He believed that the supinator longus was not a 
pronator or a supinator, but a pure flexor, and that the 
action of a muscle produced by faradism was not the same 
as that produced by the will. 

MALARIAL NEURITIS AND NEURO-RETINITIS. 

The "British Medical Journal" (March 9, 1890) has a 
paper on this subject, by N. C. Macnamara. In places 
where malaria prevails, says the author, hemicrania, sciatica, 
and loss of sight, in connection with intermittent fever, are 
not unfrequently met with. A case cited, a former tea- 
planter in Assam, had frequent attacks of intermittent 
fever ; and several times, accompanying such attacks, im- 
pairment of vision that prevented reading and writing for 
ten days or a fortnight. An attack of ague in England 
produced in a few hours marked disturbances of vision 
With the right eye he could only decipher the letters of 
Snellen 2.25 ; and with the left fingers could only be dimly 
counted. The pupils acted imperfectly to light, and were 
somewhat dilated. There was no pain, photophobia, or 



262 PERISCOPE. 

conjunctival congestion. The optic discs were completely- 
obscured by effusion, which extended into the retina. The 
retinal veins were tortuous and congested. There was no 
albumen, no sugar, in the urine. Under quinine, then 
arsenic and strychnine and a change of air, the discs gradu- 
ally cleared up. Two months elapsed, however, before the 
patient could read Snellen 1.25, In six months the optic 
discs were white; Snellen 0,5 could be read; vision in the 
right eye was £ , in the left f ; and there was no return of 
fever. 

In another instance, where there was complete blindness 
— but no suspicion of syphilis, no albumen, no rheumatism 
— full doses of strychnine and a bracing climate restored 
sight in about a year. A boy of ten recovered under simi- 
lar treatment, 

Another case added to almost total blindness the annoy- 
ances attendant upon paralysis of the left ulnar nerve, to- 
gether with great difficulty in swallowing. Within three 
months, under the anti-malarial treatment referred to above, 
complete power over the nerves and muscles whose func- 
tions had been lost was restored. In none of the cases 
cited was anaemia present, though enlargement of the spleen 
existed in every one. Kidney trouble, syphilis, and rheu- 
matism were excluded. Impaired vision remained for a 
long time the only malarial symptom. Except for it, the 
patients were practically well, unless exposed to sudden 
cold or damp. Checking the fever prevented the probable 
atrophy of the disc. 

HEREDITY AS A FACTOR IN ALCOHOLISM. 

In Paul Sollier's treatise on this subject ("Prix Aubanel," 
1889) the following generalities are given as rational con- 
clusions derived from the careful and discriminating study 
of some 350 families who have numbered one or more 
idiotic, epileptic, or mentally unsound representatives in 
the wards of the Bicetre 

I. There exists a form of passion for drink that finds 
its true place of classification somewhere between dipso- 
mania, hereditary insanity, and acquired alcoholism. This 
is hereditary alcoholism, more frequent in occurrence than 
dipsomania and having much in common with acquired 
alcoholism. 

II. Hereditary alcoholism may be identical with its 
source, or different in its manifestations, the proportion of 
the first to the second being as three to four. 

III. Hereditary alcoholism belongs to neuropathic hu- 
manity, particularly to its psychopathic division. 



PERISCOPE. 263 

IV. Causes that produce hereditary alcoholism, espe- 
cially among the descendants of drinkers, are not occasional 
or apparent. The seeming and chance causes that pro- 
duce such direful results are by no means the important 
factors we have been led to believe. The only true cause 
is that heredity creates the predisposition, the desire, to- 
gether with the intellectual and moral state that renders 
the individual powerless to resist. 

HOW WHOOPING-COUGH IS TREATED IX SPAIN. 

" L'Union Medicale" (March 6, 1890) gives the follow- 
ing, from the report of the Scientific Congress of Barcelona : 
Carreras advises in whooping-cough an application of 
resorcin to the pharynx and to the vestibule of the larynx. 
He also gives large doses of chloral to allay the excita- 
bility of the superior laryngeal nerves. Guerra y Estape 
also approves of resorcin locally, and when the cough 
becomes non-convulsive finds benefit from balsams. Cala- 
treveno employs belladonna, inhalations of benzoate of 
soda, and insufflations of powdered roasted coffee and 
sulphate of quinine mixed. He also gives doses of anti- 
pyrin, one-hundredth of a grain for every month the patient 
has lived. L. F. B. 

A CASE OF ALEXIA (DYSAXAGXOSIA). 

In the January number of the " Archives of Ophthal- 
mology," Dr. Swan M. Burnett, of Washington, reports the 
history of the following unique case : The patient was a 
clergyman, eighty-two years of age. Some weeks before, 
while assisting his servant in watering the .grass, he stag- 
gered, but did not fall, and, feeling uncomfortable, went 
into the house. He passed a comfortable night, and came 
down-stairs the next morning as usual, read the service, 
and had the customary family devotions. Soon afterward, 
however, he complained of feeling bad, was taken up-stairs, 
and almost directly went into strong general convulsions. 
Of these he had three during the afternoon and evening, 
and afterward passed into a condition of stupor, from which 
he could be roused with difficulty and for only a moment. 
At the end of three days he became conscious, but was very 
weak. On the fourth day, in the evening, he read some 
from the prayer-book, but was very much fatigued thereby. 
On the next morning he attempted to read again, but found 
he could not. 

On examination he failed to name any letter of Snellen's 
test-type correctly, even the largest. The refracting media 
were unusually clear for a person of that age, and the fundus 



264 PERISCOPE. 

of the eye did not present anything sufficiently abnormal to 
account for such a marked deterioration of vision as seemed 
to be present. 

It was not that he could not see the individual letters of 
the word, or the word itself, but that they failed to convey 
to him the same ideas they had for the last seventy or 
seventy-five years. He was unable to read anything cor- 
rectly. A word here and there might be properly called, 
but the sense of even the shortest sentence would be ridicu- 
lously misinterpreted. 

For example : The morning paper was lying on the 
table, and he was asked to read aloud: "Judge Thurman 
will formally open his campaign at Port Huron to-day." 
This he rend as follows : " John, John then the hatter his 
hat going to be h — green." 

Xo. 12, of Jager, reads thus : " The keys and he began 
playing a sad and* infinitely lovely movement." His inter- 
pretation of it was : " Was told to be and haying a a was to 
be be ing in mo on when he was crydt." 

Even these attempts at reading were made slowly and 
hesitatingly, and often with the necessity of an effort to 
decipher a word by spelling, just like a child learning to 
read. 

Having been a close student and constant reader all his 
life, he was himself aware of this being the veriest non- 
sense. 

His trouble is confined entirely to an inability to inter- 
pret the meaning of printed or written words by means of 
the impressions they make on the retina. When anything 
is read to him he understands it perfectly, and can repeat it 
accurately ; and his memory of things he has read before is 
unimpaired, and all other impressions made on his retina 
are properly interpreted. 

He can even read numbers correctly, and can tell the 
amount of a check, though unable to tell to whom it is 
drawn or by whom. 

And not only are the Arabic numerals recognized with- 
out difficulty, but he is able to interpret correctly the Roman 
numerals also. All the letters he can distinguish individu- 
ally with ease except the letter " s." To look at this is 
always disagreeable. The word " the" is seldom or never 
misinterpreted. All kinds of pictures he understands and 
enjoys. He can write either originally or from dictation, 
but is as unable to read his own writing as he is that of any 
one else or printed matter. It is necessary, however, that 
he write continuously. If interrupted, he cannot go back 
and begin where he left off. Yet it is possible for him to 



PERISCOPE. 265 

break a line in writing if he is not interrupted in his own 
line of thought. 

His memory for what he has read before is not impaired. 

The notes in this case were made nearly a year ago, and 
the patient succumbed to an attack of pneumonia on January 
20, 1890. There was no autopsy. His general mental fac- 
ulties remained unusually clear and bright to the last, and 
his bodily vigor was as it had been for many years past 
until seized with the prevailing influenza. 

The author agrees with Xieden in the opinion that the 
term " dysanagnosia" is etymologically more correct and 
scientifically preferable to either "alexia" or "dyslexia," 
the two latter being hybrids of Latin and Greek, whose 
adoption in our nomenclature should not be encouraged. 

W. M. L. 



FRONTO-FACIAL ASYMMETRY OF THE INSANE. 

Dr. R. Roscioli (II Manico, 1889, v., p. 27), having in 
mind the earlier works of Lasegue, Amadei, Venturi, etc., 
on the importance of an asymmetric formation of the frontal 
bone and the facial cranium, examined most carefully 388 
insane persons of the most various shapes, etc., and 100 sane 
persons. Entirely symmetric skulls he only found in about 
thirty per cent, of the insane and in sixteen per cent, of the 
sane subjects. 

He does not ascribe any value to asymmetry of a slight 
degree, not even for the showing of a predisposition to 
insanity. The higher degrees of obliqueness of the skull 
are found in epileptics, but also in those suffering from 
other mental diseases, and in sane persons also ; they, 
however, are to be regarded as a sign of degeneration, and 
are the more frequent the more distinct the group of diseases 
in question are to be regarded as a degenerative psychosis. 
Striking asymmetry would be able to essentially obscure 
the prognosis of a case of mania or melancholia progressing 
apparently favorably. Sommer, in his examination of 
skulls of the insane, has nearly always found cranial asym- 
metry present (Virchow's Archiv, Bd. 89 und 90) ; only 3.5 
per cent, were symmetric. In agreement with Zuckerkandl, 
Meynert, Dohrn, and others, he thinks persistent asymmetry 
may not rarely be traced back to mechanical shifting of the 
cranial bones (intra-partum). 3.5 per cent, asymmetric 
skulls corresponded to the 3.6 per cent, breech-presenta- 
tions, etc., while the first cranial position corresponds to a 
flattening of the left parietal and frontal region, and the 



266 SOCIETY REPORTS. 

second cranial position, vice versa, corresponding to the 
flattening of right parietal and frontal region in nearly the 
same frequency, usually I : 2.7 to 1 : 2.3. Those asymme- 
tries dependent on presentations of the ends of the cranium 
will be the more pronounced the greater the misrelation 
between the internal pelvis and the volume of the head. 
A narrow pelvis in the mother, a striking difference between 
the length of the large father's and the small mother's head 
will bring an influence to bear upon the child's head, which 
through these influences becomes relatively or absolutely 
too large, which cannot be otherwise than unfavorable. 
Especially is this the case in the crania of those children 
born of weakly parents, where orchitis, cerebral hyper- 
trophy, etc., add to its size. (The crania of the insane are 
known to be more capacious than those of the sane.) Per- 
haps sometimes the so-called hereditary predisposition to 
insanity may be traced back to some such individual pecul- 
iarity, and indeed to some traumatic crushing and shifting 
of the brain during labor. G. P. 



jiocietij Reports. 



NEW YORK NEUROLOGICAL SOCIETY. 

Stated Meeting, Tuesday Evening, March 4, 1890. 

The President, Dr. Geo. VV. Jacoby, in the chair. 

Dr. HENRY D. Noyes and Dr. C. L. Dana reported a 
case of 

TUMOR OF THE MEDULLA AND LEFT ANOPHTHALMUS. 

A. K., aged thirty-seven, had a severe headache for 
nearly a month, some seventeen years ago, followed by 
dimness of vision in the left eye. The centre of the visual 
field appeared dark and became almost blind in that eye in 
1875. A large cysticercus cellulosae was then removed with 
this eye. He had no further trouble until February, 1888, 
when there was a recurrence of a similar headache in the 
same part of the head, on the left side at first, later general. 
Other symptoms then began to manifest themselves : ver- 
tigo, tinnitus aurium, numbness and weakness and exag- 
gerated reflexes upon the right side, paresis of the right 



SOCIE T Y REPOR TS. 267 

internal rectus, staggering to the right side, ptosis, nystag- 
mus. Later, in January, 1889, there was paresis of both 
externi, nystagmus more marked, weakness of left masseter 
and atrophy of left temporal muscle. 

February nth: Anosmia. Taste very much blunted. 
The next day epileptiform convulsions. 

February 13th : Operation for traumatic stricture. 

February 16, 1889 : Death. 

The autopsy showed three tumors in the floor of the 
fourth ventricle exerting pressure upon the left middle 
cerebellar peduncle, and slight pachymeningitis interna 
fibrosa. The left optic nerve was very much smaller than 
the right. The optic tracts were very nearly equal in size, 
but the left was a trifle larger than the right. The external 
geniculate body could hardly be made out upon the left 
side, and that on the right seemed smaller than normal. 
The left ant. corp. quad, seemed smaller than the right. 

Each of the three tumors measured some 16 mm. in 
diameter. One was on the right and two on the left of the 
median line. The one on the right was more anteriorly 
situated, extending from the middle of the pons to the post, 
corp. quad, of the two on the left side, one extended from 
near the calamus to about the edge of the pons, and was 
intimately connected with the third tumor. This last 
extended into the left half of the pons and middle cere- 
bellar peduncle. They were fairly well defined, but some- 
what infiltrating sarcomata. 

The occipital lobes were of nearly equal size. A careful 
microscopical examination had been made-and the details 
were reported. 

There was compression and more or less destruction of 
the following nervous structures : 

The left lemniscus, left pyramidal tract, left eighth, ninth, 
and tenth nerves and nuclei, left and perhaps right third 
nerves — probably the fourth, sixth, and seventh nerves, 
though these could not be examined. 

Among the more important conclusions drawn by the 
authors were the following : 

The oldest and most extensive process was on the left 
side. 

The right hemiparesis was due to pressure on the motor 
tract in the pons and medulla. The external ocular muscles 
were involved without interference with the ciliary muscle 
and iris, and in an order which confirmed the arrangement 
of the oculo-motor nuclei, as given by Hensen and Volcker, 
rather than that of Kahler and Pick, or of Starr. 



268 SOCIETY REPORTS. 

Furthermore, the case showed apparently a total decus- 
sation of the optic-nerve fibres. 

Dr. SACHS said that the unusual features of the case 
rendered discussion difficult. There was a twofold morbid 
condition, and it was not easy to determine where the one 
process began and the other endad. The symptoms were 
much more complicated than in ordinary affections of the 
medulla oblongata, as illustrated by a case at present under 
his own observation, in which there was a syphilitic tumor 
of the medulla giving rise to hemiatrophy of the tongue and 
a paresis of all four extremities, from which the patient was 
now recovering. He did not feel convinced that the ocular 
symptoms in the case of Drs. Noyes and Dana were of 
nuclear origin.. He believed that symptoms of supposed 
nuclear origin were at times found to be due to the involve- 
ment of the intra-cerebral root fibres. It was unfortunate 
that this specimen was not hardened sufficiently well to 
permit of exact determination of the parts destroyed in this 
case. 

Dr. E. D. FlSHER read a paper upon the 
PATHOLOGY OF CHOREA. 

Dr. Gray did not agree with the author's idea of the 
pathological processes in chorea. He thought the results 
of Dr. Dana's recent pathological researches in this disease 
much nearer the truth than the facts cited by Dr. Fisher. 
Nor could he quite coincide with the latter's view that 
chorea could not be relieved by peripheral measures. He 
had known of cases of chorea to recover in a few days by 
the mere change of residence from the city into the country, 
which was a salient example of the benefit of peripheral 
changes. Some years ago, when circumcision was in vogue, 
he had tried it in cases of chorea with considerable improve- 
ment. Dr. Mitchell had shown that there was a relation 
between chorea and barometric disturbance, and he had 
himself noted that in ante-cyclone periods cases of chorea 
were worse, and some of the worst cases would break out. 

Dr. Dana believed that no one as yet knew what is the 
pathological anatomy of chorea, although the truth is nearer 
than it has been before. He considered the disease to be a 
species of fright-neurosis, affecting vaso-motor centres and 
causing hyperemia of the brain. In Sydenham's chorea 
there seemed to be almost a paralysis of the vessels at the 
base of the brain. The disorder was so often due to emo- 
tional causes that it might be classed with the traumatic 



SOCIETY REPORTS. 269 

neuroses. Sometimes, of course, there was a humoral ele- 
ment in its etiology, such as gout or rheumatism. He 
thought Dr. Fisher's ideas applicable to a certain class of 
cases, though we should distinguish between Sydenham's 
and Huntington's choreas, post-hemiplegic chorea, tic, etc. 

Dr. SACHS desired to ask some of the ophthalmologists 
present as to the relations of habit chorea to ocular and 
nasal troubles, upon which so much stress had been laid. 
He believed himself in the treatment of these forms of 
chorea as ordinary cases, only that they are limited espe- 
cially to the face. 

Dr, Webster had had considerable experience with 
such cases, but it was impossible to tell what proportion 
had been relieved by ocular treatment. The majority of 
his cases had been of spasmodic nictitation, sometimes 
extending down the side of the nose and even to the lip. 
Treatment with atropine for several weeks frequently re- 
lieved them. Sometimes glasses were used in addition. 
All such cases should have any ocular defects corrected. 

Dr. Noyes felt very skeptical as to the value of the 
methods which had been suggested for the relief of these 
spasmodic affections of the face. Dr. Sachs probably did 
not refer so much to nictitation, which was often, although 
not always, due to ocular irritation as to facial tic, which 
was a very obstinate disorder and in which ocular treatment 
was not particularly valuable. A very marked case of this 
kind was that of one of the physicians in the city. Some 
astigmatism and muscular insufficiency were corrected, and 
though considerably relieved for several years, he was not 
cured. Three weeks ago he returned for further treatment, 
but he was unable to help him. Many years ago he used 
to cut the facial nerve to afford temporary relief. In chorea 
he thought the correction of eye troubles only subordinate 
to general hygienic and medical treatment. 

Dr. Knapp had also treated cases of chorea and facial 
spasm, some of them with great myopia and insufficiency of 
ocular muscles. He detailed two cases that had been much 
improved by such treatment. Other cases had shown 
scarcely any relief. He had known of a few cases operated 
upon several times, and whereas the eyes were formerly 
very good they were now incapacitated for use, and the 
facial spasm was no better. 

Dr. THOMSON said he was a decided humoralist as 
regarded the pathology of chorea. Even cases supposed to 
be due to shock and fright would be found on careful 



27O SOCIETY REPORTS. 

examination to be in reality caused by a rheumatic condi- 
tion. Rheumatism does not invariably show itself in artic- 
ular or muscular symptoms, and he had observed many 
cases without these and yet with cardiac manifestations. 
When one considered the undoubted relation between 
nervous and humoral states, — how gout, for instance, might 
suddenly disappear by fright — one could not feel like adopt- 
ing a great many causes for one definite group of facts. 
There was no reason why the rheumatic poison might not 
at one period of life manifest itself by cardiac symptoms 
and at another by articular, In the chorea of children he had 
frequently discovered endocarditis, or a rheumatic element 
of some kind in them or in their relatives, and he thought 
the poison had a selective affinity for the cerebral cortex. 
He would treat all cases of chorea, even those with local 
manifestations only, as of humoral origin. The poison 
might produce sclerotic changes in the brain possibly, as 
Dr. Fisher had suggested. 

Dr. Fisher, in closing the discussion, said he agreed 
with Drs. Noyes and Knapp that ocular defects should in 
any case be removed, although in the majority of cases no 
direct effect could be positively ascribable to the operation. 

He could scarcely agree with Dr. Thomson's statement 
as to the predominating influence of rheumatism as inducing 
chorea. Dr. Thomson's explanation of the pathological 
conditions present in chronic chorea as consisting of degen- 
erative changes in the cortex accorded with his own 
remarks in the body of the paper. He was disposed to 
believe with Dr. Gray in the good results of change of air 
and of removal of local irritation in acute cases, but in 
chronic chorea such means, while improving the general 
nutrition, did not cure the disease. 

The following nominations were made for the ensuing 
year : 

For President — Dr. Landon Carter Gray. 

" First Vice-President — Dr. B. Sachs. 

" Second " " —Dr. E. D. Fisher. 

" Recording Secretary — Dr. Frederick Peterson. 

" Corresponding " — Dr, W. M. Leszynsky. 

" Treasurer — Dr. Graeme M. Hammond. 

" Councillors — Drs. G. W. Jacoby, C. L. Dana, M. D. 
Field, M. Allen Starr, J. C. Shaw, and E.C.Seguin. 

Frederick Peterson, 

Recording Secretary. 






SOCIE TY REPOR TS. 2/1 

PHILADELPHIA NEUROLOGICAL SOCIETY. 

Stated Meeting, February 24., 1890. 
The President, Dr. H. C. WOOD, in the chair. 

Dr. J. Chalmers Da Costa read a paper on " Ophthal- 
mic Migraine." (See page 217.) 

DISCUSSION. 
• Dr. H. C. WOOD stated that he had recently been con- 
sulted, by a professor in one of the Western colleges, by 
letter. The patient was thirty-five years old, and had 
suffered occasionally from attacks, similar to those now 
present, between fourteen and twenty years of age, the 
attacks always following extra exertion. From 1876 there 
had been no attacks until the latter part of 1889. The 
professor describes these paroxysms as follows : 

" The attack begins by imperfect vision ; usually there 
appears a spot in the field of vision. Sometimes this spot 
appears to dance, at other times it simply obscures a por- 
tion of the object seen. If I run the eye along a printed 
line, as in reading, it appears exactly as if something were 
being drawn along the line, covering up the words as fast 
as I pass them. If I attempt to call the words from right 
to left, I cannot do so rapidly, but must wait for the cur- 
tain, as it were, to be drawn aside. This feature of the 
attack, which I shall designate the 'blind spot' stage, 
usually lasts twenty or thirty minutes. This is always 
present. Other features of the attack are sometimes want- 
ing. There is usually a sensation of numbness at some 
time during the attack. Occasionally it precedes the 
'blind spot' stage, but often comes on after the latter has 
disappeared. Sometimes both features are present at the 
same time. The numbness is usually in hands and fingers, 
sometimes in forearm. It is frequently in cheeks and lips 
and tongue. This numbness is not like that resulting from 
cold, neither like that from partial paralysis of a member, 
called 'being asleep;' it resembles the latter more than 
the former. When this numbness is in face or tongue, 
there is always a dancing or twitching sensation. This 
feature varies as to its time of appearance and as to its 
duration. 

" Another feature is the severe pain in the head, or 
rather in the eye. The pain seems to be in the region of 
the right eye. This pain does not begin until about the 
time the 'blind spot' stage disappears. The pain lasts 
some three or four hours. I feel quite well then until the 
next attack. It may be well to say that I now take five 
grains of antipyrine when I feel the attack coming on, and 



272 SOCIETY REPORTS. 

thus avoid much of the pain in the eye. Twice, in the last 
ten attacks, I did not take the antipyrine immediately, and 
the severe pain in the eye on those two occasions shows 
that the almost absence of pain on the other eight occasions 
was due to its use. As well as I can remember, I have had 
about fifteen of these attacks within the last four or five 
weeks." 

In subsequent letter Professor stated that he had 

discovered that his mother had suffered from attacks pre- 
cisely similar to his own, even to the numbness and imper- 
fection of vision. 

There are one or two points worthy of note in regard to 
these cases. In the first place, as to the theories suggested 
to account for the disturbance. I think that at present any 
one has a right to believe any theory he chooses, for all our 
theories are houses built of cards, as we have not sufficient 
data to enable us to formulate a positive theory. We can 
simply say that megrim is of the nature of a nerve-storm, 
and that this nerve-storm sometimes involves various sensory 
areas, and more rarely even the motor areas. 

I think that in this country severe ophthalmic disturb- 
ances are infrequent. I can remember but one pronounced 
case of ophthalmic megrim; possibly, when there is much 
disturbance of vision, the cases go to the oculist, rather than 
to the neurologist. 

Many years ago Trousseau alleged that there is a rela- 
tionship between megrim and epilepsy. I have seen many 
cases of epilepsy and many cases of megrim, but I have 
never yet seen a family in which megrim alternated in suc- 
cessive generations with epilepsy. I have seen only one 
case of megrim in an epileptic, and in that instance there 
seemed to be no relation between the paroxysms of epilepsy 
and those of megrim. There may, however, be a form of 
megrim which is epileptic megrim, just as you may have 
epileptic gastralgia and epileptic sensory discharges in 
other parts of the body, replacing the ordinary epileptic 
motor discharges. But the rare occurrence of such cases is 
no more proof of relationship between epilepsy and ordinary 
megrim than is the occurrence of epileptic gastralgia evi- 
dence of a relation between epilepsy and ordinary stomach- 
ache. 

Dr. James Hexdrie LLOYD. — I know very well a patient 
who has been the subject of ophthalmic megrim since child- 
hood. The symptoms are similar to those referred to by 
Dr. Wood's case. The vision becomes blurred and indis- 
tinct, the idea of a curtain before a part of the field of vision 



SOCIE 7 Y REPOR TS. 273 

being rather a happy expression of this. This passes off in 
ten or fifteen minutes, and is replaced by severe headache, 
unless, before that develops, the patient obtains relief by 
saline cathartics. I have associated the occurrence of these 
attacks with gastric disturbance, although usually the 
patient is not sick at the stomach until after the storm has 
taken place. These attacks recur periodically two or three 
times a year. In regard to the hereditary nature of this 
affection, I believe that one of the patient's grandfathers 
suffered with it. 

Dr. J. Madison Taylor. — I too might add a word of 
personal experience. Myself and a large number of my 
relatives suffer from what seems a true migraine — headaches 
of regularly periodical recurrence, and seemingly unrelated 
to accidental causes, always excepting worry or nervous 
strain. These begin in childhood, reach a climax of sever- 
ity in early adult life, and then happily lessen, both in 
frequence and severity, till they sometimes cease. 

In certain instances it is strictly one-sided, and often 
localizable in one spot. It is almost always accompanied 
by increased pain on using the eyes, but no marked visual 
disturbances. It is interesting to note and satisfactory for 
me to report that neither in the score or so of cases thus 
reviewed, nor in the remainder of a pretty large connection, 
is there any instance of true nervous disorder, except here 
and there a little neuralgia, nor indeed of any of the dia- 
thetic diseases. 

The paroxysms are accompanied by coldness of the 
extremities, with seemingly increased heat of head. The 
one drug which most efficiently relieves, as I have discov- 
ered after much search, is atropia, especially used hypo- 
dermatically. The instant the peripheral arterioles begin 
to relax their spasm, under the benign influence of this 
rapidly acting drug, the heart quiets down, pain lessens, 
and, along with this, the often more distressing nervous 
depression and restlessness. 

I hazard the conjecture that, whatever be the fons et 
origo of this disorder, it is usually complicated by a certain 
amount of intestinal disturbance and faecal reabsorption. 
The phenomena of aparoxysm closely resembles ptomaine 
poisoning, and the treatment suitable for each is much the 
same. 

Dr. H. C. Wood. — I have noticed in at least one case 
that during a paroxysm of megrim the jewelry about the 
person became distinctly tarnished by a sulphurous emana- 
tion from the skin : a suggestive fact in connection with the 
question of ptomaines. 



274 SOCIETY REPORTS. 

Dr. G. E. DE Schweinitz. — I have had the opportunity 
of studying a number of cases of ordinary migraine, and 
some examples of typical ophthalmic migraine. The most 
remarkable series of hemicranias which have come under 
my observation, and which should probably be classed as 
ophthalmic, are those recorded by Dr. Weir Mitchell and 
myself, in which the prodromal visual disturbance took 
the form of an apparition. As these cases have already 
been published in detail, I shall not now refer to them 
further. 

In a certain number of my cases of migraine, hemian- 
opsia, numbness of the mouth, and numbness of the left 
upper extremity preceded the attack. In one such case I 
made examinations of the eyegrounds during the paroxysm, 
without, however., observing phenomena worthy of special 
record. In two of these cases ascending doses of cannabis 
indica, pushed to the point of tolerance, afforded the great- 
est relief. Another curious symptom that I have noted, in 
addition to the depression which follows intense pain, is 
that during and after the attack a mental state, amounting 
to melancholia, appears. In one such case after the parox- 
ysm the patient is in a condition in which he fears that he 
either has done or will do some great wrong. I do not 
know whether this is the result of depression from great 
pain, or whether it is part of the nerve-explosion. As Dr. 
Wood has said, you may build as many theories in regard 
to the cause of migraine as you choose, but they fall like 
houses of cards. One theory, which has been much dwelt 
upon in modern times, is that all forms of migraine depend 
upon imperfect ocular balance and disturbances of vision. 
That these frequently are the origin of a host of violent 
headaches no one can deny, but that they alone are the 
cause of the complex phenomena which make up an attack 
of ophthalmic migraine, or indeed of ordinary migraine, is 
at least doubtful. It should be remembered that patients 
the subjects of migraines sometimes have two headaches : 
one, the hemicrania, as in a case recently seen with Dr. Weir 
Mitchell, in which the paroxysms were preceded by numb- 
ness and scintillating scotomata, and in which general treat- 
ment is efficient ; and a second, usually persistent, frontal 
or occipital headache, the result of eye-strain or insufficient 
ocular muscles, and which is cured by the appropriate ocu- 
lar therapeutics. I do not believe that the various forms of 
heterophoria, or refraction-error, cause true ophthalmic 
migraine, nor have I ever seen a case of this kind cured by 
their correction alone, however much this may have aided 
in the favorable result. I have investigated a number of 



SOCIETY REPORTS. 275 

cases of migraine and epilepsy, and have never found any 
association, nor have they seemed to have had a common 
cause. 

HYSTERICAL AMBLYOPIA IN A COLORED GIRL NINE YEARS 

OF AGE. 

Dr. G. E. DE Schweinitz. — I wish to report a case of 
amblyopia of hysterical origin occurring in a colored girl 
nine years of age. The child was brought to the dispensary 
of the Hospital of the University of Pennsylvania because 
she claimed that the left eye was sightless. The right eye 
was slightly myopic, otherwise healthy, and with the cor- 
recting lens the vision rose to normal. In the left eye there 
was a perfectly normal oval optic disc, healthy in color, and 
the retina natural. The refraction was hypermetropic. 
The child denied even light-perception, although the pupil 
reacted normally to the changes of light and shade. 
Remembering the observation of Bernutz, that the con- 
junctiva in hysterical cases is frequently anaesthetic, I tested 
this in the child under discussion, and found it as insensitive 
as if the eye had been cocainized. A further examination 
revealed complete left hemianesthesia. The ordinary tests 
with prisms, as well as that one proposed by Dr. Harlan, 
of this city, readily demonstrated the presence of vision in 
the eye in which light-perception was denied. The child 
had had no disease except measles ; the mother, a mulatto, 
was healthy. The treatment consisted in the administra- 
tion of some water colored with the compound tincture of 
cardamom, care being taken to impress upon the parent as 
well as the child the importance of" giving exactly the dose, 
the impression being conveyed that the medicine was most 
powerful in its action. 

The case gradually improved, and now, after a number 
of months, vision almost normal in amount has returned to 
the eye for which previously blindness had been claimed. 
It was practically impossible to make any determination of 
the color-fields of the right eye, or of the left eye, since the 
patient has admitted a return of vision. 

It is not always easy to classify correctly that form of 
blindness which is called hysterical, because, to quote the 
able paper of Dr. Hill-Griffith, " it is sometimes doubtful, 
as some one has remarked, if the subjects should be con- 
sidered as patients or as culprits." 1 should like to hear 
the opinion of the members of the Society on this point, 
and on any other points which may help to explain this 
curious form of amblyopia. 



276 SOCIE T Y REPOR TS. 

I have made the following interesting experiment in 
these cases, namely, in one case of simulated blindness 
(malingering) the subject was made to understand, by hav- 
ing the tests explained to her. that those present at the 
examination fully understood that her statements in regard 
to a lack of sight in the eye under examination were totally 
false. She was sufficiently intelligent to appreciate that 
she had been detected in her attempt at deceit, and readily 
admitted the charge. On the other hand, a perfectly intel- 
ligent woman, the subject of hysterical amblyopia, in whom 
the tests demonstrated the fact that the eye claimed for 
blindness had full visual acuity, utterly denied the possi- 
bility of sight, in spite of the fact of her apparent perfect 
appreciation of the sufficiency of the tests which had demon- 
strated that she could see. 

Dr. Charles K. Mills reported a case of 

EMBOLISM OF THE RADIAL ARTERY. 

The following case was seen in consultation with Dr. J. J. 
Healy : The patient, fifty-two years old, had symptoms of 
hepatic and pulmonary congestion. In about three weeks, 
when he had nearly recovered, but while still in bed, he 
was taken suddenly with intense pain in the front of the 
arm between the median line and the radial border, about 
two inches below the elbow. The pain extended to the 
forearm, hand, and fingers, which became practically help- 
less. All the fingers, with the exception of the little finger, 
were blue and cold, as were also, but to a less extent, the 
entire hand and forearm upward to the site of the initial 
pain. The greatest pain, blueness, and coldness were in 
the thumb and middle finger ; they were like "dead fingers," 
and were almost completely paralyzed. All movements of 
the fingers, hand, and wrist, but particularly those of flexion, 
were much impaired, and slight swelling was present, but 
no real oedema. 

In about twenty-four hours the lividity had considerably 
abated, and in forty-eight hours circulation was fairly re- 
established. The patient, however, continued to suffer 
greatly and was in a highly nervous state. 

He was first seen by me ten days after the onset. A 
small swelling could be felt at the position of the first pain ; 
the radial pulse on this side had disappeared, and the closed, 
cord-like vessel could be easily traced. He had great 
pain on pressure, following the line of the vessel, and con- 
siderable but less hyperesthesia over the entire radial half 



SOCIETY REPORTS. 27 "7 

of the forearm ; as the ulnar border was approached, the 
pain and hyperesthesia diminished and disappeared. He 
complained greatly of feelings of coldness and pain here, 
and also in the thumb and fingers, except the little finger. 
Gradually the circulation was more fully restored, and the 
pain and weakness subsided. At the time of my last visit 
to the patient, four weeks after the occurrence of the em- 
bolism, he still complained of some coldness, tingling and 
pain in the hand, especially in the thumb, which continued 
to be more paretic than any other part. The treatment 
employed was chiefly local warmth, counter -irritation, 
internally anodynes and tonics. For the present stage, 
massage has been recommended. 

The points which seem most worthy of consideration by 
a neurologist are the cause and characteristics of the pain, 
the nature of the paralysis, and the proper treatment. 
Embolism of the cerebral arteries apparently causes but 
little pain, doubtless because of the absence of nerves in 
the cerebral substance. In the extremities, and largely 
elsewhere, nerves, sensory or mixed, are in close relation 
with the arteries ; the radial nerve, for instance, closely 
apposed, lies to the outer side of the artery. The persist- 
ing pain and hyperesthesia in these cases are much as in a 
true neuritis. 

DISCUSSION. 

Dr. Wharton SlNKLER. — Some years ago I had the 
opportunity of seeing a lady who had several attacks of 
embolism of vessels, the result of extreme disease of the 
mitral valve. The first attack in which I saw her occurred 
while she had her arm elevated combing her hair. The 
right arm suddenly dropped motionless ; there was violent 
pain in the arm ; the limb was cold, and there was no pulse 
at the wrist or at the bend of the elbow. The power of 
motion returned on the following day ; the radial pulse did 
not return. 

Some months later she had embolism of one of the cere- 
bral vessels, giving rise to temporary right hemiplegia and 
aphasia. Later there was another attack, but I do not 
recall the vessel involved. The first attack occurred some 
six years ago, and the patient died only a few days ago ; 
but I do not know what was the cause of death, as she died 
in another city. 

Dr. WHARTON SlNKLER reported "A Case of Pericar- 
ditis occurring during an Attack of Acute Chorea in a Child 
Nine Years of Asre." 



Asglmu ilotes. 

THE TREATMENT OF THE ACUTELY INSANE IN GENERAL 

HOSPITALS. 

Last year a revised code of lunacy laws, under the 
name of the Gallup Lunacy Bill, passed the New York 
Legislature, and only failed to become a law by the oppo- 
sition of the Governor. The same bill is to be introduced 
again at the present session. The New York Neurological 
Society, at its January meeting, appointed a committee, 
consisting of Dr. Frederick Peterson, Dr. Charles L. Dana, 
and Dr. Ralph L. Parsons, to examine and report upon this 
proposed new law. After commenting favorably upon 
some very excellent features of the bill, and after vigor- 
ously opposing the method of commitment prescribed 
therein, this committee closed its report at the February 
meeting with a number of recommendations, among which 
one in particular is deserving of careful attention, because 
of the novelty of the suggestion. We refer to the following : 
"A clause should be introduced into the bill providing that 
nothing in the lunacy laws of the State shall be construed 
to interfere with the reception and treatment of acute cases 
of insanity in chartered general hospitals, in the same man- 
ner and under the same conditions as patients suffering from 
other diseases are there received and treated, provided such 
hospitals have suitable accommodations approved by the 
State Commission in Lunacy." 

In our opinion, this is the most valuable portion of the 
committee's report, for it suggests a step forward in the line 
of a great reform. The day of huge aggregations of persons 
with chronic and acute insanity in the palatial caravansaries 
known as asylums, where the mere attendance to the physi- 
cal wants of the patients is o(ten deemed sufficient thera- 
peusis, is about to pass away. The insane are no longer to 
be considered in the light of dangerous criminals, and asy- 
lums are not always to bear the stigma of existing as a 
species of jail. What is the fate of a person with acute, 
curable insanity — one that could recover in from three 
weeks to three months — when sent to one of these "cathe- 
dral" institutions? His personality is entirely lost in the 
horde of from six hundred to two thousand mad people 
among whom he is placed. The superintendent, usually 
busy with the farming and plumbing, seldom has time to 
see the patients. A young assistant physician, commonly 
of small experience, takes the patient in hand along with 
the two hundred that he is to see twice daily. He cannot 
spend more than three hours if he will with the two hundred 
patients, because the clerical work required of him consumes 



ASYLUM NOTES. 



279 



not only most of his day, but part of his night. The patient 
is considered, not as an individual, sick and requiring treat- 
ment, but in relation to the other patients of the ward. 
Does he disturb others ? Then narcotize him. If that is 
impossible, put him into the pandemonium known as the 
"back ward." There his sick brain, before haunted only by 
his own phantasmagoria, beholds materialized the hideous 
specters of his imagination. And it is doubtful if any one 
in delirium* has ever seen aught to compare with the waking 
nightmare of a "back ward" in some asylums. 

Doubtless most asylum authorities do all in their power 
to improve the environment of their charges as far as is 
possible under present conditions, but proper individualiza- 
tion must necessarily be unattainable in such a concourse 
of people and with such small assistance. Hence it is that 
of late the question of radical reform in the present methods 
of caring for the insane has become more and more promi- 
nent. They are hereafter to be treated, at least in the 
earliest stages of their aberration, like other sick persons, 
only with greater delicacy and care, because the most com- 
plex and sensitive organ of their bodies is the one that is 
diseased. 

We read of the provision of reception-houses in New 
South Wales and Queensland, and of lunacy wards in public 
hospitals in Victoria, for the treatment of insanity in its 
early stages. A psychopathic hospital with a hundred beds 
is about to be built in London, the administration of which 
is not to differ from that of a general hospital. The staff is 
to consist of a resident medical officer of asylum experi- 
ence, and assistant, four visiting physicians, a consulting 
surgeon, an ophthalmologist, an aurist, a laryngologist, a 
gynaecologist, and a pathologist. A still later step in the 
direction of reform is the organization of an out-patient 
department at the West Riding Asylum, near Wakefield, 
England, which is calculated to change the present routine 
line of action completely with regard to the early treatment 
of the insane poor. 

With these facts in mind, we cannot speak too favor- 
ably of the action of the committee of the New York Neuro- 
logical Society. Their proposition to place it in the power 
of the sixty-three chartered general hospitals of this State 
to open special wards for the reception of the acutely insane, 
under the same conditions precisely as other classes of 
patients are received, would lead to vast improvement in 
the early and efficient treatment of the nutritive disorders 
of the brain. It would create a number of reception wards 



280 ASYLUM NOTES. 

in various parts of the city and State, where there is now 
absolutely no place for such purpose. Bloomingdale is 
overcrowded and about to be removed from the city. The 
method will lead to greater individualization, a deeper 
scientific study of insanity, and the training of nurses and 
practitioners for the better recognition and care of insane 
patients in their own homes, and many will recover without 
having attached to their name and reputation the inevitable 
stigma of having been in an asylum. — N. Y. Med. Journal, 
Feb. 22, 1890. 



100k H&ewinus. 



A Treatise on Headache and Neuralgia, including 
Spinal Irritation and a Disquisition on Normal and 
Morbid Sleep. By J. Leonard Corning, M.A., M.D., 
Consultant in Nervous Diseases to St. Francis' Hospi- 
tal, the Hackensack Hospital, etc., etc. With an Ap- 
pendix : Eye-Strain, a Cause of Headache. By David 
Webster, M.D., Professor of Ophthalmology in the New 
York Polyclinic; Surgeon to the Manhattan Eye and 
Ear Hospital, etc. E. B. Treat & Co., Second Edition. 

No physician of average intelligence can fail to extract enjoy- 
ment from the perusal of this, the second edition of Dr. Coming's 
book on Headache and Neuralgia. For several years past this 
accomplished physician has devoted much attention to the practical 
management of pain ; indeed, no one among the present generation 
of physicians in this country, it is safe to say, has written or accom- 
plished as much in this important field. We say accomplished, 
since the author of this volume is not only endowed with keen per- 
ceptive power and rare originality, but likewise with a forcefulness 
and lucidity of style which facilitates the transfer of knowledge, and 
renders the perusal of his writings rather a pleasure than a task. 

Space does not permit us to review in detail this excellent 
volume ; but we have no hesitation in saying, that in no other 
monograph on headache with which we are acquainted is so much 
that is original and practical to be found. Many of the suggestions, 
regarding the management of pain, whether intra-cranial, extra- 
cranial, spinal or neural in its origin, is in the highest degree orig- 
inal and suggestive. 

As regards Dr. Webster's appendix on Eye-Strain as a cause of 
headache, we have likewise only words of commendation to offer. 



BOOK RE VIE WS. 2 8 I 

The first chapter of this part of the book treats of "Headaches 
dependent upon Errors of Refraction ;" the second deals with 
"Headaches dependent upon Impaired Accommodation ;" the third 
is devoted to "Headaches dependent upon Insufficiency of the 
Extrinsic Ocular Muscles;" and the fourth and final chapter gives 
a series of cases illustrative of the efficiency of "Graduated Tenot- 
omy of the Ocular Muscles," when the conditions are such as to 
warrant operative interference of this sort 

In contradistinction to much of the recent literature on this 
subject, Dr. Webster's statements are eminently cautious and con- 
servative. While cheerfully recognizing the importance of elimi- 
nating morbid conditions of the eves as an adjunct in the treatment 
of minor functional disturbances, he is careful not to jeopardize the 
authority of his position by that short-sighted exaggeration which is 
the true birthmark of a weak judgment. 

While cordially recommending this excellent treatise, we heartily 
congratulate both Dr. Webster and Dr. Corning on the admirable 
manner in which each has performed that portion of the allotted 
task for which he is so admirably suited. 

Practical Electricity in Medicine and Surgery. 
By G. A. Liebig, Jr., Ph.D., and George H. Rohe.M.D. 
Illustrated. F. A. Davis, Publisher. 383 pages. Price, 
$2.00 net, 

This most excellent book is divided into three parts. Part I. is 
devoted to physics and, as well, discusses the various forms of 
electrical apparatus likely to be of use to the general physician. 

Part II. is physiological. The variations of reaction in disease 
and the diagnostic value of these modifications is here discussed. 

Part III. is therapeutical. 

The authors make no claims to originality, and state that they 
"have endeavored to place in the hands of the student and practi- 
tioner an intelligible account of the science of electricity and a 
trustworthy guide to its applications in the practice of medicine and 
surgery." The work undoubtedly deserves a place on the book- 
shelves of every doctor who desires to inform himself on electricity. 
To be read carefully as to its physics, physiological and diagnostic 
data. The instruments recommended are certainly the best in their 
way. The authors at least deserve credit in not pushing theoretical 
deductions as to therapeutical value to absurd length. This part 
of the book is concise, and contains the latest accepted views as to 
the practical application to various morbid conditions. So much 
rubbish has been allowed to enter this part of books on electricity 
that the reviewer had hoped that positive and original clinical obser- 
vation by the author would have made it more concise in some parts 
and more at length in others The book is certainly, however, a 
scientific guide and will not mislead the student or disappoint the 
physician. It is well printed and fully illustrated. 



282 books received. 

The International Medical Annual and Practi- 
tioner's INDEX FOR 1890. Edited by P. W. Williams, 
Secretary of Staff, assisted by a Corps of thirty-six 
Collaborators, European and American. Six hundred 
octavo pages. Illustrated. Cloth, $2.75 : E. B. Treat, 
Publisher, 5 Cooper Union, New York. 

This is the eighth yearly issue of the handy reference one-volume 
•lanual. It perpetuates the well-earned reputation of the preceed- 
lg issues. We especially commend the special departments of 
thermo-therapeutics by Percy Wilde, M. D. 1 he careful resume in 
the field of electro-therapeutics by A. D. Rockwell, M.D. ; Sanitary 
Science by D. S. Davies, M. B. Lond. D. P. H. Cantab, and the 
various special departments of neurological medicine. It is truly of 
great practical value to the medical practitioner, and deals with new 
ideas and is abreast of the times, saving much time in journal read- 
ing. There is a slight increase in its size, but its cost remains the 
same. 

Practical Lessons in Nursing. i2mo, cloth. $1.00 
each. Published by J. B. Lippincott Co., Philadelphia. 

They comprise so far several very interesting little books for 
professional men to read, especially for the busy specialist to obtain 
valuable and practical knowledge in other fields of medical practice 
than their own. The latest is on " Diseases and Injuries of the 
Ear, their Prevention and Cure." By Charles Henry Burnett, A.M., 
M.D. There is certainly no one more capable to write upon this 
subject than he. The work is in no need of criticism, and praise is 
unnecessary. We commend it to our readers who desire to be 
informed on the subjects treated in a concise, direct and readable 
form. 

The Literary Digest, a Weekly Summary of the Cur- 
rent Literature of the World. Funk & Wagnalls, Pub- 
lishers, 18 Astor Place, New York. Subscription price, 
$3.00, ten cents a copy. 

The first number is commendable and interesting. In this busy 
age, and especially to the physician, a periodical of this kind is a 
boon. The best thoughts, investigations and discussions appear in 
current periodical literature; and to have this epitomized by able 
men is a desideratum. We wish the journal all success. 



BOOKS RECEIVED. 

Practical Photo-Micrography by the latest Meth- 
ods. By Andrew Pringle, F.R. M.S. New York, 1890 : 
The Scovill & Adams Company, Publishers, 



books received. 283 

The Neuroses of the Genito-Urinary System in the 
Male, with Sterility and Impotence. By Dr. R. Ultz- 
mann, Professor of Genito-Urinary Diseases in the 
University of Vienna. Translated by Gardner W. 
Allen, M.D., Surgeon in Genito-Urinary Department, 
Boston Dispensary. Philadelphia and London, 1890: 
F. A. Davis, Publisher. $1.00 net. 

Transactions of the American Neurological Asso- 
ciation, 14th Annual Session, held at Washington, 
D. C, September 18, 19, and 20, 1888. Published by 
"Journal of Nervous and Mental Disease." Price, 
$1.00. 

St. Bartholomew's Hospital Reports, Vol, XXXV., 
1889. Edited by W. S. Church, M.D., and W. J. Wal- 
sham, F.R.C.S. London : Smith, Elder & Co., Pub- 
lishers. 



PAMPHLETS, PERIODICALS, ETC., RECEIVED. 

Seventh Annual Report of Philadelphia Polyclinic 
and College for Graduates in Medicine, em- 
bracing Polyclinic Hospital, the College Department, 
and the Second Annual Report of the Ladies' Aid 
Society of the Polyclinic Hospital (1890). 

Mineral Springs of the United States. By Judson 
Daland, M.D. 

Intermediate Trachelorrhaphy. By H.J. Boldt, M.D. 
Reprint from Vol. XIV., Gynecological Transactions, 
1889. 

A Case of Alexia (Dysanagnosia). By Dr. Swan M. 
Burnett. Reprint from " Archive of Ophthalmology," 
Vol. XIX. 

Thirtieth Annual Report of State Asylum for 
Insane Criminals, Auburn, N. Y. 

Twenty-second Annual Report of the New York 
Orthopedic Dispensary and Hospital, 1889. 

The Insanity of Doubt. By Philip Coombes Knapp, 
A.M., M.D. Reprint "American Journal of Psychol- 
ogy-" 



284 books received. 

Methods of Examinations in Medico-Legal Cases 
involving Suits for Damages. By Philip Coombes 
Knapp, A.M., M.D. Reprint from "Boston Med. and 
Surg. Jour," 

The Nightingale. Edited by Sarah E. Post, M.D. New 
York. 

Contributions to Orthopaedic Surgerv, Fourth Fas- 
ciculus. By John Ridlon, A.M., M.D. 

Enucleation of Tuberculous Glands. By Thos. W 
Kay, M.D. Reprint from the " Medical Register." 

The Seventeenth Annual Report of the Metro- 
politan Throat Hospital for the Treatment 
of Diseases of the Nose and Throat. New York. 

The Home-Maker. Edited by Marion Harland and Grace 
Peckham, M.D. 



ptiscellami. 



[Reprinted from the Proceedings of the American Association fur the Advance- 
ment of Science, 1889, p. 26.] 

Report of the Committee ox Anatomical Nomenclature with 
special reference to the brain. 
During the past year, some of the members of the Committee 
have given the subject intrusted to them as much time as their regu- 
lar duties would permit. They agree upon one point, viz.. the 
advantages, other things being equal, of munonyms, (single word 
terms) over polyonyms (terms consisting of two or more words). 
Before making specific recommendations or presenting a final re- 
port, the Committee think it advisable that they and other anatom- 
ists should have an opportunity of discussing at leisure the simpli- 
fied nomenclature which they are informed is employed in certain 
treatises which will be published during the coming winter. They 

therefore ask to be continued. 

Burt G. Wilder, Chairman. 
Harrison Allen, 
Frank Baker, 
Henry F. Osborne, 
T. B. Stowell, 

Committee. 



MISCELLANY. 285 

Note by the Chairman. — The treatises referred to in the above Repoit are 
Leidy's " Human Anatomy," and the following articles in Wood's: " Reierence 
Handbook of the Medical Sciences, - ' vol. viii., by E. C. Spitzka, "bpinal Cord " 
and "Histology of the Brain;" W. Browning, "Vessels of the Brain;'' S. H. 
Gage and B. G. Wilder, "Anatomical Terminology;" B. G. Wilder, "Anatomy 
of the Brain," "Malformations of the Brain," and "Methods of Dissection," etc. 



Preliminary Report of the Committee on Anatomical Nomencla- 
ture, ADOPTED DEC. 28, 1889, BY THE ASSOCIATION OF AMERI- 
CAN Anatomists without dissent. 

"The Committee recommend: 

1. That the adjectives dorsal and ventral be employed in place 
of posterior and anterior as commonly used in human anatomy, and 
in place of upper and lower as sometimes used in comparative 
anatomy. 

2. That the cornua of the spinal cord, and the spinal nerve- 
roots, be designated as dorsal and ventral rather than as posterior 
and anterior. 

3. That the costiferous vertebrae be called thoracic rather than 
dorsal. 

4. That the hippocampus minor be called calcar ; the hippocam- 
pus major, hippocampus ; the pons Varolii, pons ; the insula Reilii, 
insula; pia mater and dura mater, respectively pia and dura." 

Signed by all the members. 

Joseph Leidy, Chairman. 
Harrison Allen, 
Frank Baker, 
Thomas B. Stowell, 
Burt G. Wilder. 

Thomas Dwight was added to the Committee. 

The Committee desire frank and full expressions of opinion 
from scientific and medical journals, from individuals who receive 
copies, and from any others who are interested in the subject. 

Burt G. Wilder, Sec'y. 
Cornell University, 
Ithaca, N. Y., Jan. 6, 1890. 



286 MISCELLANY. 

NOTICE. 

TENTH INTERNATIONAL MEDICAL CONGRESS. 
To be held in Berlin, August 4th to qth. 

The Committee of Organization of the Tenth International Medi- 
cal Congress, R. Virchow, President • E. von Bergmann, E. Leyden, 
W. Waldeyer, Vice-Presidents ; 0. Lassar, Secretary-General, have 
appointed the undersigned members of an American Committee for 
the purpose of enlisting the sympathy and co-operation of the 
American profession. 

We are assured that the medical men of our country will receive 
a hearty welcome in Berlin. The Congress promises to prove of 
inestimable value in its educational results, and in securing the ties 
of international professional brotherhood. It is most important 
that the American profession should participate both in its labors 
and its fruits. 

Delegates of American Medical Societies and Institutions, and 
individual members of the profession, will be admitted on equal 
terms. The undersigned, therefore, beg to express their hope that 
a large number of the distinguished men of our country will appre- 
ciate both the honor conferred by this cordial invitation and the 
opportunity afforded us to fitly represent American medicine. 

The Congress will be held at Berlin, from the fourth to the ninth 
of August. 

The arrangements in regard to a few general meetings and the 
main scientific work, which is delegated to the sections, are the same 
as in former sessions. A medico-scientific exhibition, the programme 
of which has been published a few weeks ago, is to form an ingre- 
dient part. It is to the latter that the Berlin Committee is very 
anxious that both the scientific and the secular press should be 
requested to give the greatest possible publicity. 

The office of the Secretary-General is Karlstrasse, 19, N. W., 
Berlin, Germany. 

S. C. Blsey Washington, D. C. Wm. T. Lusk, New York, 

Wm. H. Draper, New York. Wm. Osler, Boston, Mass. 

R H. Fitz, Boston, Mass. Wm. Pepper, Philadelphia, Pa. 

H. Hun, Albany, N. Y. J. Peyre Porcher, Charleston, S.C. 

A. Jacobi, New York. J. Stewart, Montreal, Can. 



VOL. XV. May, 1890. No. 5 

THE 

Journal 

OF 

Nervous and Mental Disease. 



©riginal Articles. 



HYPNOTISM ; 

WITH A CRITICISM ON SOME RECENT EXPERIMENTS AT 

LA SALPETRIERE. 

By FREDERIC BATEMAN, M.D., F.R.C.P., 

Senior Physician to the Norfolk and Norwich Hospital; Corresponding Member of the Academy 
of Medicine of Pans; Hod. Member of the New York Neurological Society; Cor- 
responding Member of the Psychiatrical Society ot St. Petersburg, etc. 

PERHAPS no branch of physiology has received so 
much attention of late years as the localization of 
cerebral faculties ; and thanks to the researches of 
recent observers, among the most distinguished of whom 
are some of our own countrymen, the localization of func- 
tion stands out in bold relief from the ordinary course of 
events, as marking an epoch in the history of medicine, to 
which there is nothing parallel in modern times ; but 
although the motor region of the cortex cerebri has been 
mapped out with marvellous precision and exactitude, a 
less satisfactory result has been attained in reference to the 
localization of sensorial centres, and this remark applies 
especially to the visual centre ; for, although, thanks to the 
labors of Ferrier, Schafer, Sanger-Brown, and others in this 
country, and of a host of scientific workers on the Continent 
and in America, a flood of light has recently been thrown 
upon it, I am justified in saying that in the year of grace 
1890, the most conflicting views prevail in reference to this 
branch of cerebral physiology — the exact localization of 
the visual centre. 



288 FREDERIC BA TEMAN. 

I can readily imagine that some of my readers may say, 
What can the visual centre have to do with hypnotism and 
with the Salpetriere experiments ? I trust to be able to show 
that the subject I am considering has a direct bearing on 
the physiology of vision, and the communication which I 
venture to make to this journal may be deemed as sup- 
plementary to an essay on the visual centre which I have 
lately published in a scientific journal, " Les Archives de 
Neurologie," edited by M. Charcot. 

Perhaps few subjects have attracted more attention lately 
than hypnotism, or the production of artificial sleep, and as 
some remarkable experiments made at La Salpetriere have 
recently been brought under my notice, I have been induced 
to make them the subject of a communication to this jour- 
nal, and I am especially induced so to 'do, as I do not 
agree with the inference that the originators of these 
experiments have sought to deduce from them ; and here I 
would remark that by the influence of Charcot and Richet at 
Paris, Bernheim and Beaunis at Nancy, and Hack Tuke in 
this country, men of science are turning their attention to 
the study of hypnotic phenomena, instead of leaving them 
to charlatans and unscientific observers. 

As the result of Professor Charcot's experiments in 
hypnotism, two conditions have been described, called 
respectively "hysterical lethargy" and the "cataleptic 
state." 

It is reported that most cases of grave hysteria can be 
thrown into the first of these two conditions by directing 
the eyes to be fixed steadily on some point — the tip of a 
penholder held in the hand, for instance ; in a few moments 
the head inclines to the right or to the left, the eyelids 
close, the limbs become motionless and limp, but the power 
of speaking remains. This is the condition of hysterical 
lethargy in which, amongst other symptoms, there is 
marked neuro-muscular excitability, a phenomenon first 
observed by M. Charcot, and which he designated "hyper- 
excitabilite neuro-musculaire des hypnotiques," and which 
consists of the aptitude of voluntary muscles to contract 
under the influence of simple mechanical irritation. 



HYPNOTISM. 289 

It is easy to cause the patient to pass from the hypnotic 
condition to the cataleptic stage. All that is required is to 
open the eyelids and allow the retinae to be stimulated by 
the rays of light ; the patient immediately becomes cata- 
leptic, but a remarkable difference is observed between the 
two sides, as shown by the following experiment made by 
M. Lepine, one of M. Charcot's assistants. 

A female patient is hypnotized ; if asked to speak, write 
or make any gesture whilst in this condition, she obeys. 
The left eyelid is then opened and the left retina stimu- 
lated, thus plunging the right hemisphere into a state of 
catalepsy ; there is no change from a linguistic point of 
view ; the patient continues to speak, to write and to gesti- 
culate. The process is modified ; the left eyelid is closed 
and the right opened with corresponding stimulation of the 
right retina, thus plunging the left hemisphere into a state 
of catalepsy ; immediately all communication with the ex- 
ternal world is suppressed, the patient can neither speak, 
write, nor gesticulate. " Le masque facial reste muet." A 
moment before, when the right hemisphere was in a cata- 
leptic condition, every form of language subsisted ; now 
that a similar condition is induced in the left hemisphere, 
language of every kind is abolished. 

The above experiment was repeated in the case of 
another patient who knew by heart some pieces of poetry. 
Whilst in the hypnotic state, she repeated certain verses 
distinctly. The left eyelid was raised, but she continued 
her recitation ; but on the left lid being closed and the 
right opened, thus producing catalepsy in the left hemi- 
sphere, she straightway ceased to speak in the middle of a 
verse, sometimes even in the middle of a word. On closing 
the right eyelid, she began her recitation again at the very 
place at which she left off, recommencing sometimes in the 
middle of a word. 

M. Ballet, in commenting upon the above curious phe- 
nomena, lays great stress upon their value as experiments 
in vivo, tending to confirm the results of clinical observa- 
tion, which would place the seat of speech in the left 
anterior lobe to the exclusion of the right. Now, I am not 



29O FREDERIC BATEMAX. 

intending to enter upon the question as to whether the 
speech-centre, if there be one, is situated in this or that 
part of the brain ; I have discussed this subject at consider- 
able length elsewhere. This is not the time or the place to 
discuss the general question of the localization of speech, 
but I simply moot the question as to whether the deductions 
drawn from these experiments are not open to doubt. I 
think they are ; at all events they are certainly not beyond 
the reach of fair and legitimate criticism. 

In the first place, although the results claimed for them 
are so startling and of such momentous importance, I am 
not aware that they have even been confirmed by subse- 
quent observers. I find that my scepticism is shared by no 
less an authority than Professor Bernheim of Nancy, who, 
in a private communication to me, attributes the phenomena 
observed to "suggestion." "It has been thought," says he, 
"at La Salpetriere, that the hypnotized, whilst in a state of 
lethargy, are unconscious and do not hear ; whereas they 
hear everything, and often strive to guess what the observer 
is desirous of eliciting from them. A hypnotized person 
who has never witnessed Charcot's experiments, and who 
is not aware of what is desired of her, will certainly never 
exhibit the phenomena described. It is certainly an affair 
of sitggestion ; the experiments are misleading, and can in 
nowise help to solve the difficult questions connected with 
the pathology of aphasia." 

My iriend, Dr Hack Tuke, whose researches upon this 
subject are so well known, has favored me with a letter in 
reply to my inquiry, in which he says that he has never 
been able to convince himself that hypnotic experiments, 
which appear to support the alleged function of Broca's 
convolution, are free from that subtile and constant source 
of fallacy — unintentional suggestion. In an article on 
"Artificial Insanity," in the "Journal of Mental Science" 
for 1865, and also in his "Influence of the Mind upon the 
Body, with especial Reference to the Imagination" (1872), 
Dr. Tuke has insisted on the numerous influences of imagina- 
tion and suggestion in so-called animal magnetism and 
hypnotism. 



HYPNOTISM. 29I 

Furthermore, whilst engaged in writing this paper, my 
attention has been called to a report of a curious illustration 
of the effects of hypnotic suggestion, lately witnessed at 
St. James' Hall, London. It is stated that a mesmerist 
threw a gentleman, named King, into a mesmeric trance 
so profound that the passage of a needle through the fleshy 
part of his arm caused no sensation. In this state, Mr. King 
gave humorous lectures and very curious imitations of 
Mr. Gladstone, Mr. Irving, Mr. Grossmith, and Dr Parker. 
He was told by the mesmerist that he was each and all of 
these persons, and, quite unconsciously, he accepted the 
responsibility : the will became the slave of a suggestion ; 
an automaton was substituted for the true volitional self. 

Moreover, Professor Charcot himself, as I have else- 
where stated, admits that hysterical mutism can be pro- 
duced artificially by hypnotism ; and in the appendix to 
the third volume of his " Diseases of the Nervous System," 
one of his pupils, M. Cartaz, thus describes in detail how, by 
hypnotic suggestion, hysterical mutism is produced : Dur- 
ing the period of somnambulism the patient is made to 
converse ; the observer, then lowering his voice, says to 
her: " I don't understand you. What do you say? Why, 
you can't speak," and in an instant the patient is aphasic, 
being unable to speak or to phonate. This, says M. Cartaz, 
is the exact representation of the mental disturbance ob- 
served in hysterical patients. 

Whilst, therefore, recognizing the scientific interest 
attaching to these curious experiments, I cannot admit that 
the inference that has been drawn from them is a logical 
one ; and I think they should not be cited as confirmatory 
of the localization of speech in the left hemisphere. 

I am not at all sure that there may not be also an ana- 
tomical objection to the deductions which have been drawn 
from these experiments. 

In a former paper I have entered at some length into the 
consideration of the different theories of the visual centre, 
and I have shown that the whole subject is far from being 
definitely settled, as the most divergent notions exist as to 



2Q2 



FREDERIC BA TEA/AX. 



the course of the fibres at the optic chiasma, between it and 
the mesocephalic ganglia, and again between these and the 
cerebral cortex. 

Moreover, Charcot's assumption, that there is a supple- 
mentary crossing of the fibres of the optic tracts in the 
corpora quadrigemina, by which all fibres from one retina 
would pass to the opposite hemisphere, is by no means 
recognized as absolutely correct ; indeed, Charcot himself 
speaks of it as only an hypothesis, not based at present on 
any anatomical grounds, but nevertheless supplying a ready 
means of presenting, in a very simple form, the rather com- 
plex facts revealed by clinical observation. 

I need scarcely point out that if there be no other decus- 
sation of the optic fibres but that which is said to take place 
at the chiasma, stimulation of one retina should affect both 
hemispheres equally, and the Salpetriere experiments would 
lose all their import — that is, assuming that the prevailing 
opinion is the correct one — that the crossing of the fibres at 
this point is only partial. I am aware that this partial 
decussation is not admitted by all anatomists, and that the 
course of the optic fibres is still a matter of dispute : in fact, 
certain German anatomists, Biesiadecki, Mandelstamm, and 
Michel maintain that the fibres of the optic nerves undergo 
complete decussation at the chiasma, as occurs in fishes, 
amphibia, reptiles, and birds ; and that the semi-decussation 
is to be looked upon simply as a theory, which, however, 
explains the facts observed in clinical medicine. I find that 
Ferrier also, in describing Charcot's scheme, characterizes 
it as unsatisfactory, and in contradiction with now well- 
established clinical as well as experimental facts. 

It is therefore clear that the exact course of the fibres 
of the optic nerves is still undefined, and perhaps no ques- 
tion of late years has excited so much controversial discus- 
sion as the exact determination of the visual centre. The 
whole subject of the course of the fibres of the optic tract, 
and of the nervous connections of the retina with the brain, 
is discussed in an exhaustive manner by Professor Grasset, 
of Montpellier, who rejects the schemes both of Charcot 
and of his pupil Fere, for which he substitutes one of his 



HYPNOTISM. 293 

own, frankly admitting, however, that it is purely hypo- 
thetical, but may be useful as a means of graphically repre- 
senting the actual state of our knowledge of this difficult 
subject of cerebral semeiology. M. Grasset recognizes three 
decussations of the optic fibres: 

1st. Semi-decussation at the chiasma, where the internal 
fibres cross, whilst the external fibres continue in a direct 
course. 

2d. The external fibres cross in the neighborhood of the 
corpora quadrigemina, so that by this arrangement the 
decussation is complete, and thus all the optic fibres from 
one eye are reunited in the internal capsule of the opposite 
hemisphere. 

3d. The external fibres undergo a further decussation, 
beyond the internal capsule, before terminating in the con- 
volutions of the hemisphere, and by this means each occipital 
lobe will contain the external fibres from the eye of the 
same side and the internal fibres from the opposite eye. 

M. Grasset adds that this triple seat of partial decussa- 
tion seems to be indispensable for the proper interpretation 
of certain clinical facts ; as to the exact locality in which it 
occurs, he suggests that it may be in the corpus callosum. 
He admits that the above arrangement is somewhat com- 
plex, but that the facts to be explained are of a no less 
complex character also. 

Another author, Michael Foster, in writing upon this 
subject, says that the nervous centre is not a double centre 
with two completely independent halves, one for each eye ; 
there is a certain amount of communion between the two 
sides, so that, when one retina is stimulated, both pupils 
contract. The authors of the Salpetriere experiments, of 
course, assume that one retina only is stimulated, and only 
one hemisphere plunged into catalepsy. 

Besides the conflicting opinions as to the points of 
decussation of the optic nerves, there would seem to be a 
further objection to the acceptance of the inference drawn 
from the Salpetriere experiments in reference to the locali- 
zation of the faculty of language. In order to establish any 
connection between these experiments and the localization 



294 FREDERIC BATEMAN. 

of speech, it is necessary to assume that the fibres of the 
optic tract find their way into the anterior lobes of the brain, 
the supposed seat of speech — which is by no means univer- 
sally admitted. 

The course of the fibres of the optic tract between the 
external geniculate body and the cortex of the brain is not 
well ascertained, and is still the subject of scientific inquiry ; 
at all events, a great diversity of opinion exists in reference 
to it. Gratiolet asserted that the optic tract is directly con- 
nected with every part of the cerebral hemisphere in man, 
from the frontal to the occipital region ; and Professor 
Hamilton, of Aberdeen, in a communication to the Royal 
Society, on " The Cortical Connection of the Optic Nerves," 
expressed the same opinion. 

In treating of this subject, that careful and accurate 
observer, Dr. Ross, says that both anatomical and physio- 
logical, as well as pathological observations, make it certain 
that most, if not all, of the fibres of the optic tracts termi- 
nate in the cortex of the occipital lobes, but that the course 
of the fibres in the intervening space between the cortex 
and the external geniculate body, is the subject which has 
excited the greatest controversy. 

From a private communication with which Dr. Gowers 
has favored me, he speaks most emphatically upon this 
point, and says that his views of the physiology of the 
cortex would exclude altogether the idea of any passage of 
fibres from the optic tract to the motor speech region. 

I have thought it desirable thus to enter at great length 
into the consideration of the bearing the experiments made 
at La Salpetriere, upon persons in a state of hypnotism, may 
have upon the localization of functions, but I must think 
that our knowledge of the exact construction of the visual 
centre, of the precise distribution of the fibres of the optic 
tract, and of the relation of the two visual centres to each 
other, is at present so imperfect as not to justify the origi- 
nators of the above interesting experiments to quote them 
as evidence of the localization of speech in any part of the 
left hemisphere of the brain. 






A STUDY OF CEREBRAL PALSIES OF EARLY 

LIFE, BASED UPON AN ANALYSIS OF ONE 

HUNDRED AND FORTY CASES* 

By B. SACHS, M.D., 

Professor of Nervous and Mental Diseases at the New York Polyclinic, 
AND 

By F. PETERSON, M.D., 

Lecturer In the Department of Nervous and Menial Diseases at the New York Polyclinic. 

FEW diseases are better known or more thoroughly 
understood than infantile spinal paralysis. Its clin- 
ical symptoms and its pathology have been definitely 
determined, so that poliomyelitis anterior acuta scarcely 
needs further study. The very opposite is true of infantile 
cerebral palsy. While there is but a single form of disease 
included under the term infantile spinal paralysis, we are 
forced to admit that there are several different forms of 
cerebral palsy. The attempt to fix upon certain cases of 
cerebral paralysis in children and to label them infantile 
cerebral palsy as a direct analogy of the better known spinal 
disease has led to great confusion, although we shall see 
that there is some justice in drawing this analogy. Nor is 
it entirely correct to speak of cerebral spastic palsies as 
distinguished from atrophic paralysis, for we shall report at 
least two cases in which the element of spasticity was 
entirely wanting, although the cases were undoubtedly of 
cerebral origin, the proof of which was furnished by the 
post-mortem examination in one of these two cases. 

The large majority of the cases with which we are here 
concerned represent spastic forms of paralysis and as re- 
gards the distribution of the palsy may very properly be 

* Read at the stated meeting of the New York Academy of Medicine, April 
3, l8 9°- 



296 B. SACHS AND F. PETERSON. 

divided into cases of spastic hemiplegia, of double spastic 
hemiplegia or diplegia, and of spastic paraplegia. Since the 
clinical subdivisions are so easily made, it would seem to 
be a curious fact that these cases have been so poorly 
understood and so little studied. There were many rea- 
sons for this : first and foremost, the great difficulties in 
obtaining autopsies, the majority of these cases either living 
on to a very advanced age, or else dying in almshouses, 
where no interest was taken in them ; then again, the con- 
dition was so frequently associated with idiocy; or the 
individuals were regarded as hopeless cripples that did not 
possesss sufficient interest to repay careful study. And 
lastly, the term infantile cerebral palsy proved to be a 
stumbling-block. A number of cases and some few 
autopsies were reported, disclosing a variety of lesions ; 
there seemed to be little hope of bringing order out of 
chaos. The truth of the matter, that we had a number of 
different forms of disease and a variety of pathological 
processes to consider, was a long time forthcoming. We 
hope to show by this paper that much of the confusion that 
has surrounded this subject will be removed if we consider 
that a variety of morbid symptoms may give rise to any of 
the three forms of paralysis, and that the character of the 
paralysis will depend upon the site and extent of the morbid 
lesion. But for the difference in the areas of the brain 
affected and the degree of irritation or destruction of brain 
substance, the symptoms in all these cases would be very 
much the same. 

The subject which we present has a live interest at this 
present time, and yet it is nearly fifty years ago since the 
first work in this field was done. In 1842, Prof. Henoch 
wrote his inaugural dissertation, " De Atrophia Cerebri," 
and gave an excellent account of infantile cerebral paraly- 
sis. 1 Heine 2 referred to these cases in a monograph on 
spinal paralysis of children, published in i860. Little 3 was 
well acquainted with them. In 1868, Benedikt, 4 the neuro- 
logist, described them. The French schools soon took up 
the subject, and Cotard/ Wuillaumier, 6 Bourneville/ wrote 
important papers on spasmodic infantile paralysis, some of 



CEREBRAL PALSIES OF EARLY LIFE. 297 

them referring to the anatomical features of these diseases. 
As recently as 1883, several English authors (among them 
Hadden ? and Ross 9 ) published the clinical details of a small 
number of cases and the accounts of a few autopsies. 

Two publications have stirred up the recent discussion 
on this question. The first was Kundrat's 11 ' monograph on 
porencephalus, in which this one morbid -state was care- 
fully studied. The second was Strumpell's 11 paper in 1884, 
in which he suggested that infantile cerebral hemiplegia 
was due to a polioencephalitis acuta. This single state- 
ment which was decidedly original, but had no post-mortem 
proof, has raised a great hue and cry which have not yet 
subsided. Whatever other good it may have accomplished, 
Strumpell's theory has at least imbued an old subject with 
new life. His article was quickly followed by a number of 
valuable contributions, among which those of Ranke, 1 " Bern- 
hardt, I3 Wallenberg, 14 Kast, 15 Jendrassik and Marie, 16 Gowers 17 
and Hoven 16 are by far the most important of the European 
contributions. In America, able articles have been written 
by Dr. Sarah McNutt, 19 Drs. Sinkler, 20 J. Lewis Smith, 21 
Knapp, 22 Lovett 23 and Gibney. 2 * Chief and foremost of all 
is an exhaustive monograph by Prof. Osier, 23 in which 151 
new cases were analyzed with a skill which characterizes 
all of Prof. Osier's work. 

There would seem to be some need of an apology after 
this for the study of another series of cases. Our first 
reason for doing this is, that the work preparatory to this 
paper was begun several years ago, before the publication 
of Prof. Osier's monograph. Secondly, we had some views 
of our own to advance; and, lastly, the unusual number of 
cases at our disposal called for special elaboration. 

The cases here reported upon were, with very few ex- 
ceptions, examined by one of the authors of this paper. We 
are greatly indebted to Dr. Gibney and Dr. Townsend for 
referring the greater number of these cases to us from the 
Hospital for the Ruptured and Crippled. Dr. Gray was 
kind enough to allow us to use the notes on cases seen in 
his department. Ten of the cases were seen in private 
practice. 



298 B. SACHS AND F. PETERSON. 

The physician is no longer content, or at least should 
not be, to make the diagnosis of apoplexy; of hemiplegia, 
or of paraplegia, in the adult. It is his aim to determine 
whether the special form of paralysis be due to hemorrhage, 
thrombosis, embolism, tumor, abscess, or what not. In 
short, he studies the symptoms of each case with special 
reference to pathology of the disease. And so with infantile 
palsies: it is not enough to recognize spastic hemiplegia, 
diplegia or paraplegia, but the attempt should be made to 
determine the special morbid condition underlying each 
form. The large number of cases made it imperative upon 
us to make a distinct effort in this direction. 

In view of the small number of autopsies recorded in 
literature this effort may seem hazardous ; but a single 
autopsy in a well-observed case is a guide in the study of 
dozens of others ; and with the advances made in a knowl- 
edge of cerebral lesions, the neurologist is fortunate in 
being able to reason with a great degree of certainty from 
clinical symptoms to the morbid lesion which they indi- 
cate. 

A thorough knowledge of the clinical symptoms is, 
however, the starting point of this study. In order not to 
weary you with the details of these cases, we give you the 
conclusions to be drawn from our entire series with refer- 
ence to each point at issue. And we shall give but a few 
histories in extenso that you may recognize the chief types 
of which we treat. Before proceeding to these cases, we 
submit a table showing that of the 140 cases* there were 87 
males and 53 females; there were 105 hemiplegias, 24 
diplegias, and 11 paraplegias. 

TABLE I. —Showing the sex and form of paralysis in 1-40 cases of infantile 

cerebral palsy. 

Form of Paralysis. Males. Females. Total. 

Right Hemiplegia . . .." 37 15 52 / ,,.- 

Left Hemiplegia 546 27 £3 \ 1U0 

Diplegia 15 9 24 

Paraplegia 9 2 11 

Total 87 53 140 

Since the above was written we have seen at least fifteen additional cases, 
but we have concluded not to alter the tables in the body of this paper. 



CEREBRAL PALSIES IN EARLY LIFE. 
HEMIPLEGIAS. 



299 



CASE I. — (No, 48.) A. F., aet. four and a half years, 
male, first child, difficult labor and instrumental delivery. 
From very first day right hemiplegia. Slight athetosis and 
associated movements. Contracture at elbow, formerly 
pes equino-varus, improved by operation. All reflexes of 
right side lively. Mental condition fair. 




Fig. /.—Case IV., No. 138. Right hemiplegia with contracture and retarded 
growth of arm. 

CASE II.— (No. 58.) L. B., female, aet. nine years. Con- 
genital left hemiplegia. Labor normal ; fourteenth child ; 
movements of child ceased a few days before birth ; ex- 
pected to be still-born; weighed four pounds at birth. 
From age of two years epileptic attacks every two to four 
weeks Fine associated movements of both sides. Arm, 
leg, and face of left side involved. Very great retardation 
of growth of arm and leg ; some contractures of flexors of 
arm and wrist; imbecile; microcephalic. 



•7QO B - SACHS AND F. PETERSON. 

CASE III. — (No. 44.) L. E., female, set. eight years ; 
acquired hemiplegia ; onset at age of five years ; convul- 
sions for nine hours and coma ; could not move, talk or 
walk for three months. Face and leg have recovered con- 
siderably ; very great retardation of growth of arm. Marked 
associated movements. Contracture of right arm ; reflexes 
of right side exaggerated. 

Case IV. — (No. 138.) J. K., male, set. seventeen years. 
Right hemiplegia at eight years of age following typho- 
malarial fever ; was delirious and unconscious during nine- 
teen days ; no convulsions. After recovering from coma, 
right arm, face, and leg were found paralyzed. Complete 
aphasia and entire loss of memory of everything occurring 
before typhoid. Had to be re-educated. Athetoid and 
associated movements. Reflexes exaggerated right side. 
Enormous contracture of flexors of right hand and fingers 
and great retardation of growth of right upper extremity. 
Right leg somewhat smaller than left ; right talipes valgus ; 
asymmetry of face. Electrical reactions and sensation 
entirely normal. Has recovered speech fully and is bright, 
but several years behind others in education. Fig. I. 

DIPLEGIAS. 

Case V. — (No. 141.)* J. O., female, aet. sixteen. Con- 
genital diplegia ; mother kicked in abdomen by horse two 
months before birth of child and made unconscious thereby. 
Three other children, all healthy. Tedious labor, no instru- 
ments used, no fits or convulsions. Did not attempt to 
creep or walk ; teeth at usual age. Patient has menstru- 
ated since tenth year and was weak in back, arms and leg 
from earliest childhood. Extreme spastic contracture of 
adductors and flexors of thighs ; double talipes varus, equi- 
nus on right side. Left arm worse than right. Athetoid 
movements of left hand. Has frog walk. Intelligence 
good. Fig. II. 

Case VI. — (No. 31.) M. L., male, aet. three years. Con- 
genital diplegia. Asphyxiated during labor. Mother had 
pneumonia, and died five days post partum. Rigidity of 
arms, legs and back. Hands did not unclinch for two years. 
Frequent convulsive seizures alternately of right and left 



* This case, although under observation for a long time, was omitted from our 
list by mere accident. The history is sufficiently characteristic to deserve spec al 
mention. 



CEREBRAL PALSIES IN EARL Y LIFE. 



30I 



side, including face. Cannot talk, walk or stand. Feeble 
minded ; cross-legged position and all reflexes exag- 
gerated. 




Fig. II— Case V., No. 141. Diplegia; double talipes equino-varus, athetosis 
of left hand. 

PARAPLEGIA. 
Case VII. — (No. 50.)* C. F., male, set. one year. Con- 
genital paraplegia. First child, labor hard and dry for 
forty-eight hours. Asphyxiated. From first day up to age 
of six and a half months child had a rapid succession of 
tonic and clonic spasms affecting all the muscles of the 
body, causing rigidity of all extremities, opisthotones with 
extreme arching of back, enormous exaggeration of all 
reflexes, ankle and quadriceps clonus on slightest excita- 

* While this article was passing through the press, this child died. An autopsy 
was obtained by Dr. L. E. Holt. A caretul study of the pathological findings 
will be made and published in due time. But one other autopsy on infantile 
paraplegia has hitherto been published. 



;o2 



B. SACHS AND F. PETERSON. 



tion. Convergent strabismus ; crying continually, Mental 
condition probably imbecile. Epileptic spasms controlled 
slightly by bromide treatment. Fig. III. 




Fig. III. — Case VII., No. 50. Paraplegia. Photographed in epileptiform 



convulsion. 



CHIEFLV MONOPLEGIA. 



Case VIII.— (No. 47.) H. K., male, aet. twenty-two 
months. Acquired right hemiplegia ; onset at six months 
following convulsions during pertussis and pneumonia. 
Trace of weakness in right arm ; distinct spastic paralysis 
of right leg ; knee-jerk exaggerated ; feeble-minded. This 
case made at first the impression of a monoplegia. 



FLACCID PARALYSIS. 

Case IX. — (No. 61.) M., female, aet. two years at time 
of death. First-born of healthy parents. During the fifth 
month of pregnancy mother was thrown from a carriage 
without sustaining any serious injuries. The child born at 
full term apparently normal in all respects. At age of two 
to three months a general listlessness and nystagmus were 
observed. During its entire life child was unable volunta- 
rily to move any muscle of its body. All muscles extremely 
flaccid, but all reacted perfectly to electrical currents. There 
was not the first symptom of any mental awakening. Dur- 
ing the first year of its life child noticed light, but later on 
absolute blindness set in. There was a developmental 
defect of the optic nerves, which was reported upon by Dr. 
Knapp, a similar condition of the nerves having been 
observed in only two other cases. Hearing seemed to be 
acute. There was unusual hyperexcitability of auditory 
and tactile impressions The child never had convulsions, 
not even during dentition ; no rigidities. All reflexes lively. 



CEREBRAL PALSIES IX EARL Y LIRE. 303 

Speech was, of course, entirely wanting. The child died 
of pneumonia following bronchitis. The autopsy will be 
referred to later on. This case was made the subject of a 
special paper by one of us 26 (S.), and entitled "On Arrested 
Cerebral Development, with Special Reference to Cortical 
Pathology." This paper was a study of some of the cor- 
tical changes giving rise to idiocy, but we have since come 
to learn that the report of the case and the autopsy have a 
wider significance than was attributed to them at the time. 

Case X. — (No. 80.) H. M., male, aet. eleven and three- 
quarter years. The second of three children ; an uncle said 
to have been similarly affected. Asphyxiated at birth ; 
instrumental delivery. Began to teethe late ; teeth have 
rotted away. Made imperfect attempts to walk at fourteen 
months ; crept around on his buttocks ; both feet turned 
inward, right more than left ; learned to talk, but mind has 
always been very feeble. Has had frequent epileptic attacks, 
grand and petit mal. Both upper extremities excessively 
weak, but no rigidities. Lower extremities poorly devel- 
oped. All muscles respond to faradic current, but some of 
them so feebly that very strong currents are needed. Knee- 
jerks weak but present ; boy's father is a teacher who has 
done much with his defective mind. 

From the records herewith presented to you, you will 
infer that much as the cases differ from one another, they 
also have much in common ; they yield a distinct composite 
portrait. The child is either born with, or in its early life 
develops some form of paralysis ; a hemiplegia, a diplegia, 
or a paraplegia. In the congenital cases there has been 
some disturbance during pregnancy, or labor has been tedi- 
ous and difficult or definite cause cannot be given. In the 
acquired cases we have seen that the onset of paralysis may 
occur after acute infectious diseases, during convulsions, or 
from causes that cannot be fathomed. In the majority of 
cases there is marked spasticity and extreme contractures ; 
in two cases there is a flaccid form of paralysis ; in the last 
case reported, the knee-jerks and other reflexes were weak ; 
in all other cases the reflexes were exaggerated, at least on 
the side or sides paralyzed. Some show peculiar associated 
athetoid or other post-hemiplegic movements ; in all, there 
was more or less retardation of growth, and all stages of 
mental impairment were found from weak-mindedness to 



304 



B. SACHS AND F. PETERSON. 



complete idiocy ; a few, however, are of good mental devel- 
opment. No changes in sensibility were observed, and the 
electrical reactions were never markedly altered. 




Fig. IV. — Right hemiplegia, from age of 9 months, in a woman 36 years. 
Contracture and retarded development of paralyzed side. 

These cases and some of the symptoms they exhibit are 
referred to by the poet, historian, and the painter. The 
Duchess of Gloucester, according to Sir Thomas Moore, 
had much ado in her travail. Her son, "Richard III., came 
into this world feet foremost. Shakespeare makes " Richard " 
say of himself : 

"Deformed, unfinished, sent before my time 
Into this breathing world, scarce half made up, 
And that so lamely and unfashionable 
That dogs bark at me as I halt by them." 

In Raphael's Transfiguration, the demoniac boy has 
characteristic athetoid position of one hand. 



CEREBRAL PALSIES IN EARL Y LIFE. 305 

It is now in order to see whether our cases shed any 
new light on the understanding of these palsies, and what 
relation the facts hold to the commonly received classifica- 
tion into three distinct subdivisions. 

TABLE II. — Showing the age at onset. 



Age at Onset. 

" 2d " ... 

" 3d " 


Hemiplegia. 

y2 

27 

17 

16 


Diplegia. 

20 

1 

1 

2 

24 


Paraplegia. 

7 
2 

1 

1 

11 


Tota 
49 
30 
18 
19 


4th " 


4 


4 


*• 5th " 


4 


4 


■' 6th " 


2 


2 


" 7th " 

8tb " 


1 

5 


1 
5 


" 9th " 

'• 10th " 




— 




4 


4 


Total 


3 

105 


4 

140 



From the above table we learn that of 105 cases of 
hemiplegia 22 are congenital ; of 24 cases of diplegia 20 are 
congenital, and so are 7 or possibly 8 of the 11 cases of 
paraplegia. Diplegias and paraplegias are more likely to 
be of congenital origin, hemiplegias are more apt to be 
acquired in the first three or four years after birth ; but it is 
well worth noting that there are 22 congenital cases of 
hemiplegia (over 20 per cent, of all cases of hemiplegia); 
some of the cases noted as occurring in the first year may 
be congenital, and this would help to swell the percentage 
of congenital hemiplegias. It will not do, therefore, to 
make the broad distinction so frequently made on the basis 
of the acquired or congenital character of these palsies. 
Our table is in happy agreement with the one given by 
Osier as regards hemiplegias (15 of 120 were congenital). 
Sixty of our hemiplegic cases were developed before the 
close of the third year of life ; then there is a distinct fall- 
ing off up to the age of ten ; between ten and fifteen we 
have a few more ; in three cases the age could not be 
ascertained. Will you also note that some of the acquired 



306 B. SACHS A.XD F. PETERSON. 

cases of paraplegia or diplegia have occurred after the age 
of three years, and one or the other of these cases may 
have been congenital. 

TABLE III.- -Showing age at examination. 

Age. Hemiplegia. Diplegia. Paraplegia. Total. 

Under4vears 40 16 8 64 

Between 4 and 10 rears 26 6 2 34 

" 10 and 20* •■ U 2 1 17 

trl " 20 and 30 " 18 — - 18 

Under 40 years 7 — — 7 

Total 105 24 11 140 

This table records the ages at examination, from which 
it is apparent that diplegia and paraplegia are compara- 
tively short-lived while hemiplegias often attain a very 
considerable age. Statistics of the exact ages at death 
would t be more accurate ; but inasmuch as our material 
includes cases from every kind of institution, even from 
pauper asylums, the inferences to be made are tolerably 
correct. 



TABLE IV. —Showing causes given in 91 cases of acquired cerebral palsy. 

Causes Given. Hemiplegia. Diplegia. Paraplegia. Total. 

Convulsions 20 1 — 21 

Pneumonia 6 — — 6 

Trauma to Head 6 — — 6 

Pertussis 4 — — 4 

Measles 2 2 4 

Scarlatina 3 — 3 

Onset with fever 2 — 1 3 

Hereditary Syphilis 2 — 2 

Cerebro-spinal Meningitis 2 1 3 

Onset witn fever and convulsions 

onlv 2 - 2 

Frigut 2 — — 2 

Hyprocephalus — — 2 

Vaccinia 1 — — 

Typho-malarial Fever 1 — — 

Small-pox 1 

Tonsillitis 1 — — 

Epileptic Seizure 1 — — 

Gastro-enteritis 1 — — 

Unascertained 26 1 

Total 83 4 4 91 



CEREBRAL PALSIES IN EARLY LIFE. 307 

TABLE V. — Showing ascertainable causes in 49 cases of congenital cerebral 

palsy. 
Causes. Hemiplegia. Diplegia. Paraplegia. Total. 

Instrumental delivery, tedious labor. . 4 116 

Ante-partum trauma to mother 2 3 — 5 

Premature birth 1 2 1 4 

Asphyxia at birth — 3 — 3 

Asphyxia in twin birth — 1 1 2 

Tedious labor, breech presentation. . . 2 — — 2 

Primipara, dry birth tedious labor — — 1 1 

7 mos. child, dry birth (48 hours) ... — i 1 

Primipara (set. 45), tedious labor . . — 1 — 1 

Maternal fright (ante-partum) 1 — 1 

Uraemia of mother 1 — 1 

Pneumonia of mother (died 5 days post- 
partum), child asphyxiated — 1 1 

Convulsions of mother during preg- 
nancy, difficult la or — 1 — 1 
Mother in fever for 10 weeks, ante- 
partum .... 1 — — 1 

Unascertained 10 6 3 19 

Total 22 20 7 49 

In these tables we have analyzed, as far as possible, the 
causes in 91 acquired cases and 49 congenital cases of cere- 
bral palsies. 

Among the acquired hemiplegias the acute infectious 
diseases, including pertussis and pneumonia, play a very 
important role ; a strikingly large number have come on 
during convulsions ; in these cases the convulsions are not 
the initial convulsions of acute infectious diseases ; the 
latter are considered separately in Table VI. The cases 
that have come on with fever and convulsions are noted in 
addition ; but not wishing statistics to prove more than 

TABLE VI. — Showing the relation of convulsions to the onset of the palsi s. 
Cases in which convulsions apparently preceded or were associated with 
the palsies occurring in — 

Pertussis 3 

Pneumonia 2 

Scarlatina . . 

Dentition 

Vaccinia 

Haptit-m 

Fright 

With begipning of menstruation 

Fall on head 

Gastro-enteritis 

Total 13 

Apparently immediate symptom of a focal lesion — in 2 cases, 
idiopathic and apparently only cause of palsy— in 20 cases. 
Palsy occurring in ordinary epileptic seizure — in 1 case. 



i 8 B. SACHS AND F. PETTERSON. 

they should.it is but fair to add that in many of these cases 
fever may have been present, and that from among these 
20 cases we may allow that several, if not all, show the 
onset Striimpell claims for his cases of polioencephalitis. 
We ask you also to note that in 6 cases of hemiplegia there 
was a distinct history of traumatism, that 2 hemiplegias and 
1 diplegia were the result of cerebro-spinal meningitis ; 2 
cases of diplegia came on after measles, a fact of some 
importance. In 26 cases of hemiplegia we were not satis- 
fied with the statements elicited, and have therefore marked 
them as "causes unascertained." The table of causes in 
the congenital cases points a moral. In 16 cases of the 49, 
say in 33.3 per cent., there was some difficulty in labor, 
simple delay or instrumental delivery. The older writers, 
Little, Gaudard, 2: and others refer to this cause, but have 
tolerably favorable statistics, Little mentioning but 4 cases ; 
Wallenberg gives 6 of 160 cases, and Osier 9 of 97 cases. 
The authors mentioned referred to hemiplegia only, and 
speak of forceps delivery as the element of danger. Our 
percentage is higher, because we include all forms of cere- 
bral paralysis, and tedious labor as well as instrumental 
delivery. The moral is, that the forceps should be applied, 
if necessary, or delivery hastened by other means if pro- 
tracted labor can be averted. A child's brain and skull 
have a wonderful power of resistance, but do not credit 
them with greater virtue in this respect than they really 
possess. The mother's life is by far the more important, 
but it is well to reflect that other things being equal she 
prefers a child that is neither paralyzed or idiotic. 

As regards the mode of onset, of the congenital cases, 
it would appear paradoxical to say anything ; but in several 
cases which were distinctly congenital, attention was first 
drawn to the disease by the appearance of convulsions at 
an early day. In these cases the convulsions are due to the 
same lesion or process which is responsible for the palsy. 
In the acquired cases convulsions preceded the onset of the 
other symptoms in 36 of 83 cases of hemiplegia, and in one 
case of acquired diplegia ; loss of consciousness generally 
accompanies the convulsions ; in 6 cases there was a dis- 



CEREBRAL PALSIES IN EARL Y LIFE. 309 

tinct onset without loss of consciousness or convulsions ; 
this occurred in 4 cases of left hemiplegia and in 2 of right 
hemiplegia ; 2 of these left hemiplegias were distinctly 
syphilitic. 

TABLE VII.— Analysis of six cases in which there was onset without loss of 
consciousness or convulsions. 

Hemiplegia. Age. Cause. 

Right with aphasia 2 years Tonsillitis. 

Eight 10 mos Unknown. 

Left 2^ years Syphilis. 

Left 8 " Unknown. 

Left \% " Syphilis. 

Left 2j| " Fall on bead. 

Striimpell has made the onset with convulsions and 
fever a distinctive feature of his cases. The 6 cases referred 
to in our list answer to his description of infantile cerebral 
palsy as regards the hemiplegic form of paralysis. It is 
more natural to infer that they are not cases of polio- 
encephalitis than that they are anomalous cases of that 
class. 

On this subject of initial convulsions and loss of con- 
sciousness a word should be added, even at the risk of 
anticipating some inferences regarding the pathology of 
these palsies. Initial convulsions and loss of consciousness 
are distinctly cortical symptoms. They indicate very con- 
siderable cortical disturbance either by direct injury or by 
severe or sudden injury to any part of the brain, which 
would also imply disturbance of the cortex as of every 
other part of the brain. Relatively small injuries to the 
cortex, hemorrhages or cortical encephalitis, will bring 
about loss of consciousness and convulsions ; relatively 
large injuries to the interior need not exhibit these symp- 
toms. The exception is in cases of embolism or sudden 
hemorrhages in which the suddenness of the shock disturbs 
the entire brain. This argument was urged by one of us 28 
(S.) in a paper published some years ago in which a typical 
case of capsular hemorrhage was diagnosticated mainly on 
the line of argument just referred to ; and in examining 
statistics of Wallenberg and others with reference to this 
point, we find that convulsions occurred only in cases of 



3 IO B. SACHS AND F. PETERSON. 

embolism anywhere, and in all cortical affections, however 
slight these may have proved to be. If all cases of infantile 
hemiplegia were cases of polioencephalitis corticalis, con- 
vulsions would invariably be present, but such is not the 
case. 

The form of paralysis has been frequently referred to. 
Hemiplegia, double hemiplegia or diplegia, and paraplegia 
speak for themselves. Table I. gives the relative number 
of cases of each form in our list. Monoplegias are not 
included, although other writers had reported some such 
cases. We have seen but one case in which we were 
tempted to make a diagnosis of monoplegia, and this case 
gave distinct evidence on closer examination that the arm 
as well as the leg had been involved in the earlier course 
of the disease. The march of the disease resembles adult 
hemiplegia in this that the leg recovers very much more 
quickly than the arm for reasons that need not be given 
here. Under the heading of diplegia we have classed all 
cases in which both upper and lower halves of the body 
were involved ; in some of these one leg or one arm had so 
far recovered that the cases might have been interpreted as 
hemiplegia with an additional involvement of the other arm 
or leg; but here again on closer scrutiny we became con- 
vinced that at one time all four extremities had been 
affected. 

The involvement of the face is a matter of some doubt. 
The majority of the cases were seen at a time long after the 
recovery of the face. We can vouch, however, for the fol- 
lowing statements. The face was affected in u cases of 
right hemiplegia, in 9 of left hemiplegia, and in 2 cases of 
diplegia. In 2 cases (1 of right and 1 of left hemiplegia) 
the leg was worse than the arm ; in all other hemiplegics 
the arm was the part more affected. In all diplegics the 
legs were more affected than the arms. Trunk and neck 
muscles were distinctly involved in two cases of diplegia. 
Strabismus occurred in one of right hemiplegia, in four of 
left hemiplegia, and in three cases of diplegia. 

It has been doubted whether aphasia followed the same 
laws in the infantile hemiplegia as in the adult form, and 






CEREBRAL PALSIES IN EARL Y LIFE. 3 I I 

Bernhardt 13 has seen fit to write at length on this special 
subject. Aphasia can only be said to be present if the 
hemiplegia comes on in an individual who had already 
acquired articulate speech, hence the 49 cases of hemiplegia 
and the 21 of diplegia which occurred before the age of two 
years are excluded from this consideration and of the 
remaining 56 cases of hemiplegia the fewest dispensary 
patients or their parents could give satisfactory statements. 
We have records of 17 cases of hemiplegia with undoubted 
aphasia. Of these 17, 10 were cases of right hemiplegia 
and 7 cases of left hemiplegia. Eight of these 17 cases were 
observed by one of us (S.) in private practice. Of these 8, 
5 had been distinctly aphasic, and three of the 5 were cases 
of left hemiplegia. This relatively large proportion of 
aphasia in cases of left hemiplegia is rather striking by 
contrast with the adult cases. As we grow older we appear 
to become more and more left-brained. In earlier years 
both hemispheres are equally entrusted, so'it seems, with 
this highest faculty of speech. Bernhardt also comes to the 
conclusion that aphasia in children accompanies right as 
well as left hemiplegia. Prof. Osier notes aphasia in 13 out 
of 120 cases of hemiplegia and only one of these with left 
hemiplegia. Wallenberg's statistics give 45 cases in 94 
right hemiplegics and 17 in 66 left hemiplegics, but he 
includes all sorts of speech disturbances, and the statistics 
cannot well be utilized with regard to true aphasia. Defec- 
tive speech was noted three times in our cases of right 
hemiplegia, twice in diplegia, and in most of our 80 cases 
of idiocy. 

The reflexes are either lively or exaggerated in the 
large majority of cases. The exceptions are noted in 
Table VIII. 

TABLE VIET. — ShowiDg the condition of the deep reflexes (knee-, elbow- and 
wrist-jerks) in 11 cases in which they were not exaggerated. 

Form. Xormal. Diminished. Absent. Total. 

Hemiplegia 4 1 3 8 

Diplegia 1 1 1 3 

Total 5 2 4 11 

In all other cases the deep reflexes were exaggerated. 



312 B. SACHS AND F. PETERSON. 

The points to be noted are these : The exaggeration of 
reflexes occurs in the parts paralyzed or paretic. The great 
excitability of the reflex is often the best proof to be had 
of the former involvement of the leg or arm, although 
bilateral exaggeration of the reflexes in cases of unilateral 
paralysis must be taken into account ; owing to the extreme 
contractures of the opposing sets of muscles, the reflexes 
can frequently not be obtained. This is true particularly 
of the ankle clonus and triceps reflexes. We must note, 
however, that in several cases the knee-jerks and other 
reflexes were subnormal and in some cases absent. In 
one case (No. 50) the quadriceps clonus could be obtained. 

Disturbances of motion, such as choreiform, athetoid 
associated movements are observed with unusual frequency 
after hemiplegia, and as we have learned also after diple- 
gias in children. 

In 105 cases of hemiplegia, choreiform movements occurred in 6 
athetoid " " 2 

associated " " I 

rhythmical " 

ataxia 
tetanoid contractions 

In 24 cases of diplegia, choreiform movements occurred in 
" " " ataxia " 

" " " athetoid movements " 

" '• " nystagmus " 2 

These disturbances of motion after single and double 
hemiplegias have an unusual interest ; they all point to 
some interference with the proper transmission of motor 
impulses either of the voluntary or of the inhibitory kind. 
The changes in the pyramidal tract are no doubt largely 
responsible for these peculiar movements, and that dis- 
turbances anywhere in the motor tract may bring about 
such aberrant movements is probable from the fact that 
these movements occur from the most diverse lesions, from 
lesions in the cortex as well as from lesions of the crus, as 
shown in an unpublished case of our own. Of associated 
movements we have seen a number of happy examples. In 
one instance the movements of the paretic arm and hand 



CEREBRAL PALSIES IX EARL Y LIFE. 

A 



o l o 





A and B — Movements of the normal hand. 
a and b — Movements of paretic hand. 

following the movement of the opposite side were so con- 
siderable that we were able to take tracings exemplifying 
this fact. WestphaP has offered the theory that in health 
there is a tendency for both upper extremities to act con- 



314 B - SACHS AND F. PETERSON. 

jointly, but that inhibitory impulses permit unilateral and 
single action. In disease this inhibition is removed, and 
therefore the effort to move one arm or hand results in the 
movement of both sides. The irradiation of impulses, there- 
fore, enters primarily into this question, but it seems to us 
to be open to doubt whether this irradiation occurs in the 
brain or in the spinal centres. In every case we must call 
in cortical inhibition to explain the separation of these 
irradiating nerve currents during normal life. Greidenberg has 
gone very fully into this special topic. (Arch.f. Psych, vol.17). 
Rigidity with contracture is one of the cardinal features 
of all these palsies, and the deformity resulting therefrom, 
as a rule, leads the patients or their relatives to seek medi- 
cal advice. With the exception of the flaccid cases before 
noted, a very considerable number go on to marked con- 
tracture ©f one or several groups of muscles. Table IX. 

TABLE IX. — Showing the forms of contracture in the various cerebral palsies. 



Form of Contracture. 


Hemiplegia. 


Diplegia. 


Paraplegia. 


Total. 


Flexors of elbow 


29 


3 


— 


29 




3 




23 


1 


— 


24 


" " knee 


5 


2 


— 


R 


" " both knees 


2 




1 


— 


— 


1 


Adductors of thighs (cross-legged 




position) 


— 


13 


2 


15 




17 


— 


— 


17 


Double talipes equino-varus 


— 


5 


2 


7 




3 


— 


— 


3 




2 


— 


— 


2 



will give the main points, which need no further explana- 
tion except this, that attention should be drawn to the fact 
that cross-legged position of the legs occurs in diplegias 
and not exclusively in paraplegias, as is generally stated. 
Furthermore, that the contractures may be so extreme that 
the individual has a frog gait, as in the case of J. O., and 
that in three cases of hemiplegia there was distinct talipes 
equino-valgus, while in all other conditions there was 
either simple varus or equino-varus position. 

Why flexor and not extensor muscles are the seat of 
contracture, adductors and not abductors, is a puzzling 
question. It is probably due to the mechanical principles 
involved in the construction of joints. 



CEREBRAL PALSIES IN EARL Y LIFE. 3; 5 

A word in passing with regard to trophic disturbances. 
In many of these cases the circulation in the skin of the 
paralyzed limbs is as poor as in infantile spinal paralysis. 
There is often the same livid hue of the palsied limb. In 
all cases occurring early in life, and particularly in those of 
congenital origin, there is apt to be a very marked retarda- 
tion of growth. This was most distinct in nine cases of 
hemiplegia, three of diplegia, and three of paraplegia. 
Atrophy of the thenar eminence was observed in one case 
of diplegia, coming on after a cerebro-spinal meningitis. 

The association of epilepsy with infantile cerebral pal- 
sies is perhaps the gravest feature of these diseases. In 
our experience it is the one danger to be feared, and should 
be considered most carefully in any case of cerebral palsy 
in a child. In our list, 62 out 140 cases were afflicted with 
epilepsy, or 44.3 per cent, of all cases. There were among 
the hemiplegic cases 41 cases of general epilepsy, 9 of the 
Jacksonian type, and one case of petit mal (in all about 50 
per cent.). In 24 cases of diplegia 7 had general epilepsy 
(29 per cent.), one had Jacksonian epilepsy. In 11 cases of 
paraplegia 4 had general epilepsy (about 36 per cent.). 
The percentage of epilepsy in our own list differs but slightly 
from that given by Gaudard, Wallenberg, and Osier. In 
view of the high percentages conceded on all sides, there 
can be but little doubt that taking all cases of ordinary 
epilepsy, a very fair proportion developed in connection with 
infantile palsies. Every sign of early palsy may have dis- 
appeared, while the epileptic taint remains. A case seen 
in private practice brings this out very forcibly : 

E. B. (No. 81), girl seventeen years of age; menstruated 
at age of eleven ; third of four children. All others died of 
acute infectious diseases. Father was fifty-six years of age 
at time of birth of child. Mother was thirty years younger. 
The child has had epileptic attacks every three to four 
months for some years. No convulsions during childhood. 
Had been treated for ordinary epilepsy by many physi- 
cians ; brominized for years. Closer inquiry revealed the 
fact that about four years ago the girl had an apoplectic 
attack, and on examination we found distinct evidence of 
left hemiplegia. Very marked weakness of left side ; greatly 



31 6 B. SACHS AND F. PETERSON. 

increased reflexes ; slight mental enfeeblement and marked 
anaemia. Bromides were discontinued, the patient put on 
tonics, and is doing well, at least as well as under bromides, 
which had evidently deepened the mental apathy. 

It will be seen that the percentage of epilepsy was 
greatest in hemiplegia, but that it was a distinctive feature 
of all forms of paralysis here considered. 

Taking into account the cortical o.igin of a large num- 
ber of these cases of epilepsy, it was natural to expect a 
nigher percentage of Jacksonian epilepsies, but in most of 
these cases the original focal lesion has disappeared, and a 
general atrophy and sclerosis have been established. Gen- 
eral and not localized epilepsy is the natural result of this 
change. 

Together with the occurrence of epilepsy we should 
note the large number of cases exhibiting some form of 
mental enfeeblement. The conclusions on this point are 
presented in Tables X and XI, where we have attempted 

TABLE X.— Showing the relation of mental defect to the age of onset alsy. 

FeeUe- 

Age of Onset of Paralysis. mindedness. Imbecility. Idiocy Total. 

Congenital 6 15 14 35 

Under 3 years 10 18 6 34 

3-5 years 2 3 — 5 

5-10 " 2 3 - 5 

Over 10 years 1 — — 1 

Total 21 39 20 80 

TABLE XI. — Showing the relation of mental defect to the form of palsy. 

Form of Mental Defect. Hemiplegia. Diplegia. Paraplegia. Total. 

Feeble-mindedness 16 2 3 21 

Imbecility 31 7 1 39 

Idiocy 7 8 5 20 

Insanity (epileptic) 1 — — 1 

Total 65 17 9 81 

to distinguish between feblee-mindedness and imbecility 
and idiocy. Eighty of 140 cases exhibited some form of 
mental impairment ; 69 were either in congenital cases or 
in those acquired in the first three years of life ; 52 per cent, 
of the hemiplegic patients, 71 per cent, of the diplegic, and 
about 82 per cent, of the paraplegics were thus afflicted. 



CEREBRAL PALSIES IN EARL Y LIFE. 3 1 7 

The worst form (idiocy) was most marked in the para- 
plegias (45 per cent.), and least marked in hemiplegia, 
being found in only 6.75 per cent, of all cases. Here again 
mental impairment can be said to be in proper relation to 
the extent of the cerebral lesion which is presumably less 
extensive in cases of hemiplegia than in the other forms of 
cerebral palsies ; though we must allow that the later 
development of many of the hemiplegias may have some- 
thing to do with these results. 

As a point of special interest we wish to add that Little 
in 19 cases of paraplegias in which there was some impair- 
ment of mental condition found 13 feeble-minded or idiotic 
(68 per cent.) and 6 (32 per cent.) of good intelligence. 

TABLE XII. — Analysis of stigmata degenerationis (exclusive of contractures) 
present in 57 cases of cerebral palsy in children. 

Hemiplegia. Diplegia. Paraplegia. Total. 

Microcephalus 21 4 2 27 

Leptocephalus 19 1 20 

Macrocephalus. . 4 — 1 5 

Marked cranial asymmetry 25 — 2 27 

Marked facial asymmetry 19 — 19 

Cranium proganaeum 5 2 — 7 

" Gothic " palate 9 1 — 10 

Imperfectly developed teeth 10 1 1 12 

Supernumerary teeth — 1 1 

Hirsuteness — 1 — 1 

Neuropathic ear 1 1 2 

Strabismus 5 3 8 

As for cranial defects, 29 the table appended will give all 
the information we have, though it is well to note that in 
most cases of hemiplegia there is a flattening of the skull 
on the side of the lesion, and in almost all cases of cerebral 
palsy most of the cranial diameters are below the normal 
averages. 

In this review of clinical symptoms we have shown that 
excepting the fact of paralysis, there are no symptoms 
peculiar to infantile hemiplegia that are not also found in 
diplegia and paraplegia. While the symptoms vary some- 
what in degree in these different forms, all forms have all 
symptoms in common, excepting those of the onset. It is 
a difference of degree, not of kind. It remains for us to 
prove whether or not a study of pathological conditions 



3 I 8 B. SACHS AND F. PETERSON. 

compels us to draw a distinction between these three forms, 
and whether or not hemiplegia, diplegia, and paraplegia 
respectively represent distinct morbid entities. We shall 
see that a variety of morbid lesions is to be found under- 
lying these conditions, and that the same lesion or condi- 
tion may in the one case be responsible for a hemiplegia, 
in the other for a diplegia, and so on. And furthermore, if 
definite forms of disease are to be diagnosticated, the diag- 
nosis must rest upon other symptoms rather than the mere 
form of the paralysis. This branch of our inquiry is beset 
with great difficulties. In the scarcity of autopsies we have 
shared the fate of other writers. In spite of our very large 
clinical experience, we have but two autopsies of our own.* 
But we claim this one advantage that in both these cases 
the post-mortem findings were of very recent date — a 
great advantage, if we reflect that in most of the cases 
recorded in literature the conditions found were the final 
result of pathological processes which had continued for 
years, and which shed no light whatever upon the initial 
morbid lesion, and yet this is the salient point of the entire 
controversy. With the information gained by our macro- 
scopical and microscopical studies we have analyzed the 
records of 105 autopsies including our own. This list could 
have been enlarged if we had had access to the publications 
of Richardiere 30 and some others. Our list, however, in- 

TABLE XIII. — Analysis of pathological findings in hemiplegia, diplegia nnd 
paraplegia, based upon the most recent autopsies, including Wallenberg's 
and Osier's cases, but not those of Richardiere or Audry. 

Lesions. Hemiplegia. Diplegia. Paraplegia. 

Atrophy, sclerosis and cysts 40 19 

Porencephalus 2 4 

Hemorrhage 23 

Embolism 7 

Thrombosis 5 — 

Agenesis 1 1 

Tubercle 1 — 

General cortical sclerosis — — 1 

Total 79 24 1 

Not including 64 cases of hemiplegia with porencephalus, and 32 cases of 
bilateral porencephalus collected by Audry. 

°A third autopsy has been added since the above was written (cf. note p. 301). 



CEREBRAL PALSIES IX EARL Y LIFE. 3 [ 9 

eludes all the recent cases,* and the report of these will 
atone for the omission of those described by the older 
writers. 

The first and the most conspicuous feature of this table 
is the prominence given to atrophy, sclerosis, and cysts. 
All these are terminal conditions and are almost useless 
for the determination of the initial lesion. Cysts are no 
doubt frequently due to hemorrhages, and if this could be 
statistically shown, the number of cases due to hemorrhage 
would have been materially increased. Zacher has noted 
one case in which cystic formations occurred together with 
an osteoma, but the patient died thirty-three years after 
onset of lesion. Wallenberg has recorded an interesting 
case of cyst in the left peduncle. 

Porencephalus is a secondary condition, and although 
much has been written on this subject, we know little of its 
origin. In some cases it is probably the result of arrested 
development, due to interference with foetal circulation 
(Kundrat) ; in others it may have been the result of early 
encephalitis or even intra-uterine cerebral hemorrhage. A 
number of different lesions may bring about a condition of 
porencephalus; moreover, the term has proved to be exceed- 
ingly elastic, and what one author has termed atrophy, 
another has called porencephalus. Audry„ 3T for instance, 
has collected 64 cases of this condition, some of which in 
the other lists are labeled atrophy or atrophy and sclerosis. 
We are forced, therefore, to rely upon cases in which the 
initial lesion has not disappeared ; and here the first fact 
that is brought out with great distinctness is that hemor- 
rhage, thrombosis, and embolism, the conditions which give 
rise to adult apoplexy, are also found to be a frequent cause 
of the cerebral palsies of early life. There is mention in 
the table of a case of tubercle reported by Seeligmuller 33 
It is hardly fair to include such a case, for it was one of 
general tuberculosis in the course of which a hemiplegia 
appeared. While no other similar cases have been pub- 
lished, it is evidence of faulty logic that Seeligmuller should 

* Two cases of Kast, one by Hoven, Wallenberg, Salgo, 31 Langenbeck, 52 
Fiirbringer, "Zacher, 35 Hirt, 36 Peterson [cf. page 323 of this article], and Sachs. 26 



320 B. SACHS AND F. PETERSON. 

have inferred from this one case that latent tuberculosis is 
almost the sole cause of infantile hemiplegia. His case 
simply shows that hemiplegia may appear together with 
other symptoms, but there can generally be little doubt as 
to the nature of the process. It is for this reason that we 
have excluded from our list a case of our own in which the 
autopsy revealed a tubercle of the quadrigeminal region 
which had given rise to a hemiplegia in the course of the 
disease. 

It may be surprising to find that polioencephalitis of 
Strumpell is not referred to. It is time that we should 
define our position with regard to this question. First of 
all, in order to distinguish this from two other lesions which 
have been termed polioencephalitis inferior (progressive 
bulbar paralysis) and polioencephalitis superior (nuclear 
ophthalmoplegia), let us speak of this as polioencephalitis 
corticalis. What proof have we that there is such a condi- 
tion ? Anatomical proof, none ; we are willing to concede, 
however, that some of the many cases of atrophy and 
sclerosis may have been due to this polioencephalitis, but 
it is unfortunate for Strumpell's theory that all of the au- 
topsies made soon after the onset of the disease have shown 
other conditions, and not a polioencephalitis. But let us 
be charitable or just, and say that even these autopsies were 
not made in cases sufficiently recent. We must add, how- 
ever, that cases which correspond very closely to the cases 
which Strumpell considered typical of polioencephalitis 
corticalis showed hemorrhage, embolism, etc., of recent 
origin. Strumpell says, however, that not all cases of 
infantile hemiplegia need be due to this cause, and that all 
authors have misinterpreted his views. Is there no proba- 
bility, then, that a few or any of the cases of infantile 
hemiplegia are cases of polioencephalitis corticalis ? There 
is some circumstantial evidence showing that there is a 
brain-lesion which would seem to be analogous to spinal 
palsy of children (poliomyelitis anterior). Mobius 39 gives 
the history of two children of one family, aged one and one- 
half and three years respectively, who were stricken down 
with fever, loss of appetite, and somnolence. One developed 



CEREBRAL PALSIES IN EA RL Y LIFE. 3 2 I 

a typical poliomyelitis of the upper extremity ; the other, 
spasmodic hemiplegia without aphasia. This is striking 
clinical evidence, though some might claim it to have been 
merely a coincidence. Another proof: Strtimpell has but 
very recently reported two cases of adult apoplexy in which 
every one would have made the diagnosis — and indeed he 
made it — of embolic softening, but the post-mortem exami- 
nation revealed a condition of encephalitis hemorrhagica 
of the gray as well as of the white matter. Marie 16 who is 
inclined to support Strtimpell, expressed the opinion in 1885 
that the encephalitis would attack the white as well as the 
gray matter, and thinks that this would not destroy the 
analogy with poliomyelitis, for in that condition the white 
fibres are sometimes involved. Jendrassik and Marie favor 
the perivascular (inflammatory) origin of the condition of 
lobar sclerosis, which they have carefully described. In 
view of all this, we venture the opinion that polioenceph- 
alitis corticalis may be the cause of some of the cases of 
infantile palsies ; but, we add, not of the hemiplegia alone, 
for we have seen several cases, including one seen by the 
courtesy of Dr. Holt, in which all the symptoms were those 
of Striimpell's disease, but there was a diplegic and not a 
hemiplegic form of palsy. In these cases the cerebral char- 
acter of the symptoms was so distinct that a confusion with 
poliomyelitis was out of the question. 

We insist that, until further pathological proof shall be 
forthcoming, polioencephalitis corticalis shall be diagnosti- 
cated last, not first. In a short paper, published some years 
ago in the Journal of Nervous and Mental Disease, 
one of us insisted that there was strong reason to think, by 
analogy with adult apoplexy, that the lesion might be the 
same in the infantile form. A short abstract of that history 
will show the analogy : 

M. M. (Case No. 75), boy, two and one-half years old; 
one and one-half years previously pneumonia ; tonsillitis 
with fever up to 102°. Four days after this, typical right 
hemiplegia and aphasia, positively without coma or convul- 
sions. The onset was as typical as in the ordinary mild 
hemorrhage into the internal capsule in the adult, and the 



322 



B. SACHS AND F. PETERSON. 



progress of the disease and the mode of recovery (which be- 
came complete) were quite like what we see in" adult cases. 

In 1887 the evidence on this point was not so strong as 
it is now, and this leads again to the subject of thrombosis, 
hemorrhage, and embolism. These vascular troubles were 
generally considered to be peculiar to advanced age, with 
the exception of embolism, which every one is ready to 
concede may occur at any age in which heart-disease occurs. 
Thrombosis was thought frequent enough, from the occur- 
rence of syphilitic endarteritis in children. Hemorrhage 
in adults is attributed to the existence of miliary aneurisms. 
In the child, miliary aneurisms have been found, and Prof. 
Osier 2 " 1 has described a large aneurism of the anterior cere- 
bral artery occurring in a boy six years of age. If ather- 
amotous degeneration of the arteries be less frequent than 
in adults, another condition is found to which Reckling- 
hausen refers in his book on the " Pathology of Circulation 
and Nutrition," page 84. This is a fatty degeneration in 
the wall of the cerebral blood-vessels. Little notice has 
been taken of this, as indeed of all else that pertains to the 
vascular pathology of children. 

Meningeal and cortical hemorrhages are shown to be 
more frequent in children, while all other cerebral hemor- 
rhages are more frequent in adults. This will explain the 
more serious character of the symptoms in the young, and 
the more frequent occurrence of epilepsy and mental impair- 
ment in children. As the prognosis would be materially 
affected according to the cortical or cerebral character of 
the lesion, we have sought for the point of differential 
diagnosis between lesions so situated. To this end the 
occurrence of convulsions is specially to be considered. In 
the paper referred to it was stated : " Loss of consciousness 
is an extremely variable symptom ; it seems to depend 
rather upon the quantity of blood effused than upon the 
area involved. Not so with convulsions. A convulsion, if 
it is anything, is a cortical affair, the result of cortical irri- 
tation." To which should be added that the irritation may 
be direct or indirect ; the sudden shock imparted to the 



CEREBRAL PALSIES IN EARL Y LIFE. 323 

cortex by the occurrence of embolism anywhere in the 
brain is apt to cause convulsions, and a lesion in any part 
of the gray matter of the central nervous system may excite 
convulsions ; but hemorrhage over the cortex, even if 
slight, is apt to be accompanied by convulsions. Hemor- 
rhage into the interior of the brain, unless very large, and 
the condition of thrombosis — slow occlusion of a cerebral 
vessel — are more apt to be marked by absence of convul- 
sions and possibly also by preservation of consciousness. 
In other words, if you can exclude embolism and sudden 
and very large hemorrhage, and lesion of the lower gray 
centres, the absence of convulsions at the onset of an apo- 
plectic attack is in favor of a lesion in the interior of the 
brain rather than in or upon the cortex. Of this I am more 
certain still, that whatever may be the symptoms accom- 
panying the onset of an apoplectic attack, if the convulsions 
reappear after the initial symptoms, the lesion is cortical, 
or else an additional insult has occurred. A possible ex- 
ception might be made in favor of thalamus lesion. These 
statements are corroborated by the results of recent au- 
topsies, though only a small number of cases refer to all the 
facts needed. A case observed and examined post-mortem 
by one of us (P.) is in point : 

A. W., male, aged fifteen, bright at school, expert swim- 
mer, at age of eight or nine years was in the habit of diving 
a distance of twenty to thirty feet from a railroad-bridge. 
Shortly after this began to suffer from intense headaches, 
which gradually grew worse, until he was twelve years old, 
when mental changes began to be apparent. Gradually 
loss of memory, confusion of mind, and steady progress 
toward dementia. At the same time moroseness, melan- 
cholia, morbid fear, and coprolalia. One month after 
admission into the Poughkeepsie Asylum had a severe 
epileptic fit. Two days later right hemiplegia with constant 
right-sided hemi-epilepsy ; became comatose. The clonic 
spasms of the right side continued at intervals of several 
days, but gradually became limited to the right leg alone. 
Four days later, death. Autopsy showed the outer dural 
surface to be normal ; on the right side the subdural space 
presented a limited pachymeningitis haemorrhagica interna, 
but merely a thin organized detachable stratum of long 



324 B. SACHS AND F. PETERSON. 




Fig. VI. — Showing extent of pachymeningitis hemorrhagica over superior 
surfaces of hemispheres. 




Fig. VII. — Shewing extent of process on inferior surfaces of left hemisphere. 



CEREBRAL PALSIES IN EARL Y LIFE. 325 

standing. Over the left side, however, the pachymeningitis 
was exceedingly widespread, extending over the whole 
surface of the hemisphere, both above and below, except 
in the anterior fossa of the skull. Over the convexity of 
the hemisphere the haematoma was very thick, consisting 
of strata of various ages, some of them undoubtedly dating 
from the beginning of his symptoms. Between two and 
three ounces of fresh coagula were spread on the convexity, 
especially in the Rolandic region. The extent of the pachy- 
meningitis and hemorrhage is shown in the accompanying 
illustration. The left hemisphere was greatly compressed ; 
the brain-substance itself seemed normal. The brain 
weighed 35X ounces. The ventricles were widened and 
distended with clear serum. There was no disease of or 
injury to the cranial bones. There was no lesion of any 
kind in substance of hemispheres, ganglia, pons, or medulla. 
Figs. VI. and VII 



Thrombosis occurs in a comparatively small number of 
cases. It is due. either to the fatty change in the walls of 
the blood-vessels, or to syphilitic endarteritis, of which we 
have seen several cases, and Seibert 40 has described one, 
and is probably found in marantic cases, Gowers lays par- 
ticular stress upon the thrombosis and occlusion of smaller 
cerebral veins, and thinks this the most important factor in 
the causation of infantile hemiplegia. All that we can say 
is that he must prove this to be true ; the autopsies analyzed 
give no evidence whatever of this condition. 

Thus far we have had reference chiefly to the pathologi- 
cal lesions of infantile hemiplegia. In diplegia nothing is 
said in our table of hemorrhage, thrombosis, and embolism, 
though it is more than likely that some of the cysts referred 
to were originally due to clots, and the occurrence of menin- 
geal hemorrhages over both hemispheres giving rise to 
diplegias is well known. But these cases either die early 
before the form of paralysis is well established, or if they 
live for many years the initial hemorrhage has disappeared 
and the secondary conditions only remain. You will please 
observe, however, that what is properly termed agenesis 
corticalis occurs in a case of hemiplegia reported by Kast, 
and in the case of diplegia reported by one of us (S.) The 



326 B. SACHS AND F. PETERSON. 

microscopical changes appear to have been very similar in 
both cases — in the one case unilateral, in the other bilateral, 
which accounts for the hemiplegia in the one case, for 
diplegia in the other." 




Fig. VIII. — Outtr aspect of surface of left hemisphere, showing exposure of 
the island of Reil. (X) Region from which first block of tissue had been re- 
moved. (Cf. this journal, vol. x-14). 



In the cases of Kast and Sachs there was no evidence of 
the agenesis having been due to early intra-uterine inflam- 
mation ; in both cases there was a mere arrest of develop- 
ment and nothing more. The changes found in the case 
reported by one of us were limited to the large cells, in the 
cortex of which there was not a normal specimen to be 
found throughout the entire brain. There was no evidence 
of perivascular inflammation and only very slight thicken- 
ing of neuroglia-tissue, with considerable retardation of 
development of the white fibres entering the gray matter of 
the cortex. The changes in the cells and the atrophies of 
the surface will be seen on inspection of the two accom- 
panying figures. Figs. VIII and IX. 



* A similar condition has been fcund by Jensen 41 in a case of idiocy. 



CEREBRAL PALSIES IN EARL Y LIFE. 



327 



The pathology of paraplegia has not been determined. 
We have but one case with autopsy, that of Foerster, 42 in 
which case Birch-Hirschfeld found a general cortical scle- 
rosis with probable descending degeneration.* Ross was 
induced to state, only a few years ago, that he thought the 



7T. 



g!=^!§?sste*»,«. 






W& 




■■■■ 














<^i 



X 500 diameters. 
Fig. IX. — Section of first temporal convolution. Distortion of pyramidal cells. 
Smaller cells and neuroglia cells distinctly nucleated. 

changes of the spinal lateral columns due to traction at 
birth might be responsible for spastic paraplegia. This is a 
bare possibility ; but the occurrence of idiocy and mental 
enfeeblement in 9 out of 1 1 cases of our own and in most of 
the reported cases, and the frequent occurrence of convul- 
sions, make a cerebral origin much more probable. 

The question arises whether it is possible to determine 
the morbid lesion in any given case, and we submit the 



* See note page 301. 



328 B. SACHS AND F. PETERSON. 

following as the result of our clinical and pathological 
studies : 



The form of paralysis is not the most important factor in 
diagnosis. 

Acquired cases of hemiplegia and diplegia, but particu- 
larly the former, are apt to be due to the same causes that 
prevail in adult apoplexies ; namely, hemorrhage, throm- 
bosis, or embolism. Menirigeal and cortical lesions are 
more frequent. Absence of convulsions at onset probably 
points to an intra-cerebral lesion. Occurrence of convul- 
sions at onset points generally to cortical lesions or to 
embolism anywhere in the brain. In a few cases affections 
of gray matter lower down in the central nervous system 
may also be attended by convulsions. 

Frequently repeated convulsions after onset point with 
great certainty to cortical lesion. 

Cases coming on after acute infectious diseases have been 
proved to be due to vascular derangement, particularly to 
hemorrhage and embolism, but some cases may be due to a 
polioencephalitis corticalis ; the onset with very high fever 
and convulsions makes the latter more probable. 

Traumatism is an important factor in the causation of 
meningeal hemorrhage during early life and particularly 
during the act of labor. 

Congenital cases of diplegia and hemiplegia may be due 
to early meningeal hemorrhage and possibly to an early 
encephalitis. 

In acquired and congenital cases of hemiplegia and 
diplegia we may have either a condition of porencephalus 
or simple arrest of development. If acquired, there would 
seem to be the history of slow development of the symp- 
toms without predisposing cause. If congenital, there may 
be a history of traumatism to mother. 

In later life hemiplegia or diplegia associated with large 
amount of mental impairment and with contractures point 
to general atrophy, sclerosis, with secondary degenerations, 
or to a condition of porencephalus, the origin of which it is 
often difficult to determine. 



CEREBRAL PALSIES LV £A RL V LIFE. 329 

In conclusion, a word regarding treatment. So far as 
prophylactic measures are concerned, we wish to repeat our 
warning to the obstetrician : Hasten protracted labor, for 
the skillful use of forceps and careful manipulation are less 
apt to do injury than the prolonged compression of skull 
and brain in the pelvic canal. In the acute cases the same 
principles which obtain in the treatment of adult cases 
should be applied. 

Medical advice is generally sought for the relief of the 
secondary conditions — epilepsy, idiocy, and contractures. 
In the treatment of the epilepsy the usual remedies may be 
employed : above all, the bromides and chloral. But these 
should be administered with the utmost discretion, for in 
many cases the epileptic attacks are so infrequent that they 
do far less harm to the patient than the drugs, which in- 
crease mental stupor and are very apt to cause anaemia and 
malnutrition. The proper use of electricity and massage in 
the early stages will prevent to some extent the formation 
of extreme contractures. If such contractures exist, we place 
our reliance upon the orthopedic surgeon, who finds in these 
cases a very wide field for the exercise of his surgical and 
mechanical skill. In cases in which the hand is so deformed 
as to be of less use than an artificial hand would be, ampu- 
tation would be justified, provided there were no marked 
rigidity at the elbow. This has been thought of in the case 
of J. K., whose portrait has been shown. In one case, in 
this city, with extreme athetosis, the arm was amputated 
and the patient rendered more comfortable. This should 
be done only in the severest forms. 

The question of surgical interference in cases of hemi- 
epilepsy deserves passing, notice. In very recent cases, in 
which there is no prospect of spontaneous recovery and in 
which the character and site of the lesion can be accurately 
inferred, the idea of operation might be entertained, but it 
is wholly inadvisable in cases of long standing in which 
secondary conditions have been permanently established. 
The result in two cases of Bullard 43 and Mitchell 44 has not 
been encouraging. 

Trepannation for the relief of severe headaches and local 
epilepsy may be attempted. 



330 B. SACHS AND F. PETERSON. 

As for the condition of mental enfeeblement, much can 
be done by careful manual and mental training. This 
should be begun at an early day, and the results will be as 
satisfactory as in Bourneville's department of the Bicetre, 
where the improvement is evident from the change in the 
facial expression of patients on admission and after they 
have been under treatment and instruction for some time. 
In only two cases that we have seen of infantile palsies 
can we conscientiously state that there has been complete 
recovery. 

REFERENCES. 

i E. Henoch. — Cf also Lectures on Children's Diseases. London, 1889. 
New Sydenham Soc. Publication. 

2 J. von Heine.— Splnale Kinderl'ahmung. Stuttgart, 1860. 

3 Little. — Obstet. Soc. Trans. 1862, vol. hi 

4 M. Benedikt.»— Electrotherapie. Vienna, 1868. 

5 Cotard.— Etude sur l'atrophie partielle du cerveau. Paris, 1868. 

6 Wuillaumier. — De l'epilepsie dans l'hemiplegie spasmodique infantile. 
These de Paris, 188;:. 

7 Bourne ville. — Recherches cliniques et therapeutiques sur l'epilepsie, 
l'hysterie et l'idiotie. Paris, 1882. 

*> Hadden.— Brain, vol. vi., 1883-1884, p. 302 ; also St. Barth. Hosp. Rep., 
1882, and Brit. Med. Journ., 1882. 

9 Ross. — Brain, vol. l and vol. v.; also Dis. of Nerv. System, vol. ii., 
p. 465. 

10 Eundrat — Die Porencephalic. Vienna, 1882. 

11 Striimpell. — Jahrb. liir Kinderheilk. N. P., 1884, vol. xxii. Cf. also 
Textbook of Medicine, translated by Vickery and Knapp, p. 704 ; New York, 
1887. 

Ueber primare acute Encephalitis. Deutsche med. Wochenschr., 
Oct. 17, 1889. 

12 Ranke. — Jahrb. fur Kinderheilk.. 1886; also Munch, med. Wochenschr., 
1886. 

13 Bernhardt. — Virchow's Arch., vol. eh.. 1885. 
Jahrb. fur Kinderheilk., 1886, p. 384. 

u Wallenberg.— Jahrb. fur Kinderhiilk., 1886. 
Arch, fur Psych., vol. xix., p 297, 1888. 

15 Kast.— Arch, liir Psych., vol. xviii., 1887 p. 4.57. 

16 Jendrashik and Marie. — Arch, de Physiologie, vol. i.,,1885; also Paul 
Marie, in Progres medicale, No. 36, 1885, p. 167. 

" Gowers.— Dis. of Nerv. Syst., Am. ed., p. 801, 1888. Cf. also Lancet, 
1888, vol. i. 

Medico Chirurg. Trans., vol. lix , 1876, p. 271. 
>*Hoven.-Arch. fur Psych., vol. xix., p. 563, 1888. 

19 Sarah McNutt. — Am. Journ. Med Sciences, Jan., 1885, vol. i. 
Am. Journ. Obstet , 1885. 

.Arch, for Pediatrics. Jan , 1885. 

20 W. Sinkler.— Med. News. Phil , 1885, vol. i. 

21 J. L. L. Smith.— Journ. Am. Med. Assn., Feb. 25, 1888. 

22 P. C. Knapp.— Journ. Nerv. and Ment. Dir,., 1887, vol. xiv.,j>. 480. 
Bost. Med. and Surg. Journ., Nov. 22, 1888. 

m Lovett.— Bost. Med. and Surg. Journ.. June 28, 1888. 



CEREBRAL PALSIES IN EARL Y LIFE. 



33* 



* Gibney.— N. Y. Med. Eec, vol. xxx., p. 393. 

« Oslar.— (a) The Cerebral Palsies of Children: Monograph. Phil., 1889. 
(6) Also Phil. Med. News, July 14 to Ang. 11, 1888. 

(c) Am. Journ. Med. Sciences, 1885. 

(d) Can. Med. and Surg. Journ., 1886. 

(e) Alienist and Neurologist, 1889, p. 16, on Idiocy and Hemi- 

plegia. 

26 Sachs. — Journ. Nerv. and Mental Dis., Sept. and Oct., 1887. 
Intracerebral Hemorrhage in the Young. Journ. Nerv. and Ment. Dis., 

Aug., 1887. 

27 Gaudard. — Contrib. a l'etude d'nemiplegie cerebrale infantile. Geneva, 
1884. 

*8 Westphal.-Arch. fur Psych., vol. iv., 1873, p. 747. 

29 Fisher and Peterson. — Cranial Measurements in Twenty Cases of In- 
fantile Cerebral Hemiplegia. N. Y. Med. Journ., April 6, 1889. 

30 Richardiere. — Etude sur les sclerose encepbaliques de l'enfance. These 
de Pans, 1885. 

31 Salgo.— Centralbl. fur Nervenheilk., June 15, 1889. 

32 Langenbeck.— Quoted by Ranke in Jahrb. fur Kinderheilk. , 1886, 
p. 316. 

34 Furbringer. — Deutsche med. Wochenschr., 1889, xv., 67. 
Berl. klin. Wochenschr., p. 16. 1889. 

35 Zacher. — Arch, fur Psych., 1889, vo . xxi., p. 38. 

38 Hirt— Path, und Ther. der Nervenkrankheiten, p. 223. Vienna, 1890. 

37 Audry. — Revue de Medecine, June and July, 1888. Summary of Au- 
topsies in 103 Cases of Porencephalus. 

38 Seeligmiiller. — Jahrb. fur Kinderheilk., 1879, vol. xiii. 
^Mobius.— Schmidt's Jahrb., 1881, vol. cciv., p. 135. 

<° Seibert.— Jahrb. fur Kinderheilk., No. 22, 1885. 

41 Jensen. — Arch fur Psych., vol. xiv., p. 752. 

< 2 Forster. — Jahrb. fur Kinderheilk., vol. xv. 

« Bullard.— Bost. Med. and Surg Journ., Feb. 16, 1888. 

** Mitchell. — Referred to by Osier. Monograph, p. 102. 

In the above no attempt has been made to give a full bibliography. For 
this the reader is referred to Osier's monograph. The following articles, 
however, many of them recent, and not included in Osier's list, deserve 
special mention : 

Ashby and Wright. — Diseases of Children. London, 1889. 

J. W. Runeberg. — Fall af sa kallad hemiplegia spastica infantilis. Finska 
lak.-sallskap. hand!., 1884, xxvi., 26i. 

Bianchi. — Defetto porencephalico. La PHichiatria, Naples, IS^. 

D'Espine. — Revue med. de la Suisse Romande, March 20, 1889. 

Binswanger. — Yirchow's Arch., vol. cii., p. 13. 

Schultze.— Deutsche med. Wochenschr., 1889, p. 287. 

Fr. Ziehl.— Neurolog. Centralbl., July 15, 1889. 

Aufrecht. — Ueber das Vorkommen halbseitige Lahmungen bei Oberlappen- 
Pneumonien von Kindern. Jahrb. fur Kinderheilk., 1890, vol. xi., part. iv. 

Stephan. — Des paralysies pneumoniques. Rev. de med., 1889, No. 1, 
p. 60. 

Lepine — De l'hemiplegie pneumonique. These inaug., Paris, 1887. 

Moncorvo. — De la sclerose en plaques chez les enfants. Union Med., 
January, 1884, p. 16. 

Kirchoff. — Eine Defectbildung des Grosshirns. Arch, fur Psychiatrie, 
vol. xiii. 

E. D. Fisher. — Epilepsy and Hemiplegia of Children. Journ. of Nerv. 
and Ment. Dis., Sept.. 1888. 

S. Gee. — On Hereditary Infantile Spastic Paraplegia. St. Barth. Hosp. 
Rep., vol. xxv., 1889, p. 81. 



332 



B. SACHS AND F. PETERSON. 



A. J. Richardscn.— Lancet, Nov. 10, 1888. 

H Fritsche.— Jalirb. fur Kindeiheilk., May 10 1889. 

A. B. Marfan.— Arch, fur Kinderheilk., 1889, vol. x., p. 384. 

L. Tenchini. — Porencelalia grave bilalerale congenito. Ateneo med. 
parm. Parma, 1889, iii., 39. 

A. Pilliet. — Contnb. a l'etude des lesions histologiqnes de la substance 
grise dans les encephalites chroniques de l'enfance. Arch, de Neurol., 1889, 
xviii., 177. 

A. Weichselbaum.— Porencephalic und mangelhafte Entwick. der recht. 
ober. Extremitat. Ber. der K. K. Krankenanst. Rudolphstift. Vienna, 
1888, 385. 

Edwards. — Liverpool Med. -Chir. Journ., July, 1888. 

E. Powell.— Brit. Med. Journal, June 30. 1888. 

E. M. Sympson. —Cong, and Infant. Spastic Palsy. Practitioner, 1889, 
p. 114; also Feb. 1888. 

G. Anton. — Ein Fall von MikrocephaliemitschwerenBewegungsstorungen. 
Wien. klin. Wochenschr. . 1889. ii. 

Ter Grigoriantz. — Hemiplegie chez les enfants (103 pages). Paris, 1888. 

D. Burgess.— Manchester Med. Chron., 1888-'89, ix., p. 471. 

C. J. Nixon.— Trans. Roy. Acad. Med. Ireland 1888, vol. vi., p. 21. 

Aime M. Gibotteau. — Notes sur le developpement des fonctions cerebrales 
et sur les paralytics d'origine cerebrale chez les enfants (135 pages). Paris, 
1889. 

Max Wolters. — Augeb. spast. Gliederstarre. etc Bonn, 1888. 

Fauvelle.— Bull Soc. d'Anthrop. de Paris, 1889. xii., 227. 

Worcester. — Journ. Am. Mtd. Assn., 1889, p 302. 

Bramwell.— Stud. Clin. Mtd. Edinburgh, 1889-90, i.. 156. 



THERAPEUTIC BREVITIES. 



Under this title, the "Medical Age," Feb. io, 1890, pub- 
lishes some excellent gleanings. From the "British Med. 
Journal" is some consideration given to simulo in epilepsy, 
a remedy that Starr finds useful when the bromides fail. 
For infantile convulsions, Widerhofer, of Vienna, recom- 
mends the following as a sedative: — 

Hydrate of chloral, - - - 1 drachm. 

Distilled water, - 3 fluid ounces. 

Syrup of bitter orange peel, - 1 fluid ounce. 

A teaspoonful every two hours. (Revue general de Clin- 
ique et de Therapeutique.) 

For Asthma. 

Hydrate of chloral, 30 grains. 

Iodide of sodium, - - - - 22 grains. 
Simple syrup, ----- 4 ounces. 

In an attack, give a tablespoonful every hour. (Ibid.) 



THE RATIONAL TREATMENT OF SCIATICA. 1 

By GR.EME M. HAMMOND, M.D. 

FIFTY years ago sciatica was described under the head- 
ing of "rheumatism." In one of the leading text- 
books of the day it was tersely mentioned as follows : 
"When rheumatism attacks the nerves of the legit is called 
sciatica." The treatment recommended in the same volume 
was as limited as was the description of the disease, and 
consisted entirely in a recommendation of an anti-rheumatic 
diet and the internal administration of turpentine. Since 
then, however, sciatica has been studied in all of its forms, 
and the remedies which have been recommended for its cure 
are legion. 

Before a disease can be scientifically treated, the patho- 
logical conditions which produce it must be thoroughly 
understood. A few words, therefore, on the pathology of 
sciatica will not be out of place in this paper. 

Sciatica can properly be divided into two classes : one, 
in which the morbid changes take place primarily in the 
nerve itself; the other, where the disease begins primarily 
elsewhere and affects the nerve secondarily. The condi- 
tions which are supposed to induce sciatica by directly 
affecting the nerve are gout, rheumatism, syphilis, neuro- 
mata, traumatism, and cold ; while the diseases to which 
sciatica is attributed secondarily are extra-pelvic and intra- 
pelvic tumors, including a distended rectum, and diseases 
of the bone, particularly hip-joint disease. Of all of these 
causes, exposure to cold probably produces more cases of 
sciatica than all the other causes combined. 

It was formerly supposed that when the skin over the 
sciatic nerve was exposed to cold, and sciatica resulted, 
that the sciatica was due to neuralgia, that is, that the pain 

1 Read before the New York Neurological Society, April i, 1890. 



334 GRAlME M. HAMMOND. 

was produced by the irritation of central sensory cells. We 
know now, however, that this form of sciatica is a true 
neuritis. In mild cases, and probably in the initial stage 
of all cases, the inflammation is limited to the sheath of the 
nerve, the irritation of the delicate nervi nervorum account- 
ing readily for the localized pain along the course of the 
nerve. 'In severe cases there is not only inflammation of 
the nerve-sheath, but there is also inflammation of the inter- 
stitial tissue, which, by its increase in volume, and conse- 
quent pressure upon the nerve-fibres, may induce atrophy 
and degeneration of the nerve and consequent atrophy and 
paralysis of many of the leg-muscles. There is also, in the 
majority of cases, an exudation of leucocytes between the 
nerve and its sheath, which, by distending the nerve-sheath, 
probably accounts for some of the pain. 

In regard to the influence of gout, rheumatism, and 
syphilis as factors in the production of sciatica, I think there 
is considerable doubt. It is possible, in a very small per- 
centage of cases, that these diseases may predispose the 
patient to sciatica, or may perhaps induce it primarily, but 
clinical evidence, at least in my experience, does not give 
much support to the rheumatic, gouty, or syphilitic origin 
of sciatica. Gowers 2 believes that both rheumatism and 
gout are " potent factors in the production of sciatica," but 
holds that " cases in which the syphilitic nature of the dis- 
ease is certain are extremely rare." Anstie, 3 on the other 
hand, remarks : " But so far from agreeing with those who 
think this [rheumatism] is a frequent case, my experience 
teaches me that it is quite exceptional ; nor do I believe 
that the common opinion could ever have arisen had it not 
been for the rage that exists for connecting every disease 
with a special diathesis which the profession flatters itself 
that it understands." He is even more emphatic in his 
denunciation of gout as a cause of sciatica, and concludes 
with the remark that, in his experience, syphilis is but rarely 
concerned in producing it. 

2 Diseases of the Nervous System. 

3 Neuralgia, etc. 






RATIOXAL TREATMENT OF SCIATICA. 335 

My own clinical experience leads me to adopt Anstie's 
views. Rheumatism, gout, and syphilis are very common 
diseases in this country, and yet it is extremely rare to find 
an individual suffering' from any one of them who also 
suffers from sciatica. As assistant to the Medical Clinic of 
Bellevue Hospital, I had the opportunity of seeing a great 
number of patients suffering from these diseases. In my 
clinic at the Metropolitan Throat Hospital, which I had for 
over two years, fully ninety per cent, of the patients suffered 
from rheumatism and gout. In the neurological depart- 
ment of the Post-Graduate School, with which I have been 
connected ever since the school was organized, I have had 
the opportunity of studying very many cases of sciatica ; 
and my experience in this connection has shown that the 
vast majority of cases of sciatica have never suffered from 
rheumatism, gout, or syphilis, and that of the hundreds of 
cases of rheumatism, gout, and syphilis, a very infinitesimal 
proportion have even had sciatica. Another factor against 
the theory of rheumatism and gout causing sciatica is that 
anti-rheumatic and anti-goutic remedies, while they re- 
lieve the rheumatism and gout, fail utterly to improve the 
sciatica in the least. Again, no post-mortem evidences of 
gout or rheumatism can be found in the sciatic nerves 
after death. 

It is very probable that both rheumatism and gout lower 
the tone of the system to such an extent as to" render the 
patient more liable to an attack of sciatica than he other- 
wise would have been ; but there is little or no evidence to 
show that either of these diseases directly produces sciatica, 
or neuritis in any other part of the body, by direct action. 

Syphilis has been known, in rare instances, to cause 
sciatica, either by the pressure from gummata on the nerve- 
trunk or by causing inflammation in the nerve-sheath by 
the direct action of the syphilitic poison in the system. In 
regard to the latter, I am as skeptical as I am that the 
poisons of rheumatism and gout directly produce inflamma- 
tion in the sheath or substance of the sciatic nerve. 

Reports of cases of sciatica directly traceable to syphilis 
are uncommon. Only two such cases have come under my 
observation. 



336 GRJEME M. HAMMOND. 

Neuromata, traumatism (which includes blows, falls, 
wounds, and muscular efforts), and intra-pelvic and extra- 
pelvic tumors, all produce sciatica by the irritation of pres- 
sure, which, if it is continued long enough, induces neuritis. 
Diseases of bones and joints cause sciatica by the extension 
of inflammation to the sciatic nerve. 

It will therefore be understood, from the preceding 
remarks, that sciatica, no matter what its source of origin 
may be, is to be regarded as a neuritis, and is to be treated 
as such. Of course, if the neuritis has been induced by 
injury, by pressure, or by the extension of inflammation, it 
is absolutely necessary that these conditions should be 
removed ; but by simply removing the original cause of the 
irritation, the pain is not always arrested. In the mean- 
time the constant irritation of the sciatic nerve has resulted 
in a neuritis, which may remain long after the original 
source of irritation has been removed. 

Considering, then, that we have to deal with an ordinary 
case of sciatica due to exposure to cold, or that we have 
successfully removed the original cause of the sciatica, and 
the pain still continues, what is the most rational plan of 
treatment to be adopted ? Pathologically we have to deal 
with inflammation of the sheath of the nerve and perhaps 
of the nerve itself, and with a sero-fibrinous exudation, 
which is usually between the sheath and the nerve, but is 
sometimes in the substance of the nerve itself. Clinically 
we are confronted by pain, which may be slight or agoniz- 
ing, continuous or only present on motion, and, in old 
cases, by a certain amount of atrophy of some of the 
muscles. 

For the relief of pain the remedies used should vary with 
the extent of the suffering. In the most severe cases, where 
the suffering is intense, it is absolutely necessary to use 
morphine. When such is the case, it should be given hypo- 
dermically in doses amply sufficient to relieve all pain, and 
should be injected hypodermically, and not given by the 
mouth ; the fluid should be injected as near the nerve as 
possible, as there is some reason to believe that morphine 
has a tendency to reduce the inflammation in a nerve when 



RA TIOXAL THE A TME.XT OE SCI A TIC A. 337 

brought in contact with it. In milder cases, phenacetin, in 
a single dose of fifteen grains, which can be repeated in an 
hour if necessary, will be found to fulfill all requirements. 
Antipyrine and antifibrin can be used in place of phenace- 
tin if desired. I have never seen any benefit derived from 
the internal administration of aconitin, atropine, gelsemium, 
or turpentine, remedies which are claimed to be very useful 
in relieving the pain of sciatica. 

To relieve the neuritis itself, I depend almost entirely 
upon rest, the application of cold, and the use of elec- 
tricity. 

In regard to the value of rest in the treatment of sciatica, 
there can be no doubt. Every time the leg is moved the 
functions of the sciatic nerve are called into play. It is 
well known that the use of nerves and muscles induces a 
temporary congestion of the parts used, which would only 
have a tendency to aggravate a condition of already exist- 
ing inflammation. Now, by rest I do not mean simply for- 
bidding a patient to walk about, or even confining him to 
his bed, but I mean absolute rest to the limb, which can 
only be obtained by putting the patient in bed and applying 
a suitable splint to the leg. The splint I always use is 'the 
old-fashioned long splint, reaching from the axilla to the 
sole of the foot. It should be attached to the body by 
means of a bandage, and in the same manner fastened to 
the leg from the ankle upward to a point just above the 
patella. This leaves the thigh and the sole of the foot 
uncovered, a proceeding which is necessary for the proper 
application of the cold and electricity. The idea of using a 
splint in cases of sciatica is not original with me, though 
perhaps the method of using it is. The splint was first 
advocated by Dr. S. Weir Mitchell several years ago, and 
is, I believe, still frequently used by him. It gives the leg 
absolute rest, and should be used in all severe cases. In 
very mild cases it is not necessary. About every fourth 
day it should be removed, and passive movements of 
the joints and slight manipulations of the muscles should 
be carefully made, after which the splint should be re- 
adjusted. 



338 GRjEME M. HAMMOND. 

Cold is a most serviceable therapeutic agent. I am 
aware that refrigerating the skin over the course of the 
sciatic nerve with sprays of chloride of methyl, ether, and 
other agents which produce intense cold has been advocated 
and is frequently used. I have employed these remedies, 
and, after a careful trial of them, it does not seem to me 
that they are as efficacious as a more moderate degree of 
temperature continuously applied. It is my custom now to 
apply cold by means of ice-bags packed against the pos- 
terior surface of the thigh. This can readily be done with 
the splint on if it is adjusted in the manner just described. 
My reason for preferring this form of cold is that, it being 
continuous, it soon reaches the nerve, and materially aids 
in subduing the inflammation ; as the cold is not intense, 
the skin is never frozen. My objection to the sprays 0* 
chloride of methyl, ether, and other freezing sprays is that 
the cold is so great that the skin soon freezes, and the 
application has to be discontinued before the beneficial 
results of the cold can be experienced by the inflamed 
nerve. This is particularly true of the chloride of methyl, 
which freezes the skin as soon as it comes in contact with 
it. It seems to me that where the chloride of methyl acts 
beneficial!} - at all, it must do so as a counter-irritant, and 
not as a refrigerant. In my opinion the ether spray is far 
superior to it, as it is of a lesser degree of cold, and can 
therefore be applied for a much longer time ; but neither of 
these agents can compare to the almost continuous applica- 
tion of the ice-bags. 

Electricity, when properly applied, is one of the most 
useful and important remedies we possess for the treatment 
of sciatica, but when improperly used only serves to aggra- 
vate the disease and retard the recovery of the patient. 

The faradaic current should not be used at all in acute 
sciatica. It is an irritating current, both to nerves and to 
muscles, and is therefore contra-indicated. After the neu- 
ritis has disappeared and the muscles have become flabby 
from disease, or in old cases, where the nerve has been 
damaged and atrophy of muscles has resulted, faradaic 
applications may be beneficial, but in acute sciatica it should 
never be used. 



RATIONAL TREATMENT OF SCIATICA. 339 

The galvanic current may be applied in two ways : as 
a continuous current, and as an interrupted current. There 
is the same objection to the interrupted galvanic current 
that there is to the faradaic — that is, that it is irritative. 
Both of these interrupted currents are antagonistic to the 
principle of absolute rest, which I believe to be so impor- 
tant a factor in the treatment of severe sciatica. The con- 
tinuous galvanic current, on the other hand, is of great 
service. It allays pain, probably in part by the anaesthetic 
properties of its positive pole, probably in part by reducing 
the inflammation in the nerve. In what manner it relieves 
the neuritis is not known. It is claimed that it promotes 
the absorption of the serous exudation between the nerve 
and its sheath. However this may be, it unquestionably 
does relieve the patient, and in many instances no other 
remedy is necessary except rest. Its manner of application 
is as follows : The negative electrode should be about nine 
by four inches in size, and should be strapped to the sole 
of the foot by elastic bands. The positive electrode should 
be about five or six inches square, and should be applied 
over the gluteal region, over the point where the sciatic 
nerve emerges from the pelvis. If there are any very ten- 
der spots along the course of the nerve, this electrode can 
be changed occasionally so as to cover them. The strength 
of the current should not be such as to cause much pain, 
but should fall just short of doing so. Xo rule as to the 
current-strength to be employed can be laid down, as the 
point of toleration is different in different individuals. The 
continuous current should be applied twice daily, if possible, 
certainly once a day, for about five minutes at each seance. 
Most of the text-books recommend that at the end of each 
application of the continuous current a number of interrup- 
tions should be made in order to stimulate the muscles. 
Nothing of the sort should be done. It is opposed to the 
scientific treatment of the disease. It irritates the nerve, 
and counteracts, in part, if not altogether, the benefit de- 
rived from the continuous current. 

As for the internal administration of drugs, there is very 
little to be said. In those cases which are unquestionably 



340 GR&ME M. HAMMOND. 

syphilitic, of course anti-syphilitic treatment is indicated. 
In all other cases I think the iodide of potassium can be 
given, in gradually increasing doses, with great advantage, 
as it acts energetically in promoting the absorption of the 
serous exudation, and prevents, in a great measure, the 
formation of new connective-tissue. 

Regarding sciatica from its pathological standpoint, it 
seems to me that the measures just alluded to — that is, 
absolute rest, the application of moderate but continuous 
cold, and the proper administration of the continuous gal- 
vanic cnrrent — constitute, with proper anodynes, to tempo- 
rarily relieve pain, the rational and scientific treatment of 
the disease. In cases of moderate severity, rest, together 
with galvanism, will be the only remedies required. 

In regard to other forms of treatment, a word must be 
said. 

The use of colchicum, salicylic acid, salol, oil of winter- 
green, and other anti-goutic and anti-rheumatic remedies 
have not been followed by beneficial results in my cases, 
even where gout or rheumatism has complicated the case. 
Though the gout and rheumatism may yield to these drugs, 
the sciatica does not. 

Blisters or the actual cautery are serviceable, but do not 
compare to the action of continuous cold. When the case 
is not a severe one, blisters or the cautery may be substi- 
tuted for the cold. 

Hypodermatic injections of various substances are fre- 
quently recommended as curing cases of sciatica. Among 
these may be mentioned ether, nitrate of silver, and osmic 
acid. Their action is so uncertain, and their tendency to 
create deep-seated abscesses is so well known, that I'do not 
advocate their use. 

The following cases, taken from a series of similar ones, 
will, I think, illustrate the points of the treatment just 
advocated : 



Case I. — A German, fort}- years of age, came to my 
clinic at this school in 1888. He had contracted sciatica in 
the left leg three weeks previously while standing at his 



RA TIONAL TREA TMENT OE SCIA TICA. 34 [ 

work while a strong draft was blowing on him. He was in 
great pain and walked with difficulty. There was no his- 
tory of gout, rheumatism, or syphilis. I advised him to 
enter the hospital, but he refused to do so. I treated him 
as best I could for about four weeks, seeing him twice or 
three times a week. At the end of that time there was but 
slight improvement. He then entered Mt. Sinai Hospital, 
where he remained three weeks. While he was there he 
says " he took medicine, was told to keep quiet, and had a 
battery used on him five times." At the end of three weeks 
he reappeared at my clinic worse than he was before. He 
signified his willingness to enter the hospital ; so I put him 
to bed at once, put the affected leg in a long splint (reach- 
ing from the axilla to the foot), packed ice-bags on the 
posterior surface of the thigh, gave orders that he was not 
to leave his bed, and had the continuous galvanic current 
applied, in the manner I have just mentioned, twice a day 
for five minutes at a time. In three days the pain had 
entirely ceased. I then left off the ice-bags ; on the same 
day I removed the splint, and, after slight passive move- 
ments of the limb had been made, replaced it. This I did 
every three days. At the end of sixteen days the patient 
was discharged cured. I have seen him several times since 
then. There has been no recurrence of the attack. 



Case II. — A woman, forty-two years of age, with a 
decidedly rheumatic history. When I first saw her, on 
October 12, 1889, she had been suffering from a severe 
attack of sciatica in the right leg for over three weeks. It 
was not known how the attack originated, as there was no 
history of exposure to cold. Her family physician, believ- 
ing it was of rheumatic origin, had treated her with salol 
and oil of wintergreen, but without materially lessening her 
sufferings. Morphine has been used to allay the pain. The 
treatment described in the history of the first case was 
carried out in this case, with the addition of the iodide of 
potassium in gradually increasing doses. 

For the first three nights it was necessary to give mor- 
phine ; but each night a reduced dose was given. On the 
fourth, fifth, and sixth nights the morphine was omitted, 
and ten grains of antipyrine were given at bed-time. After 
that no anodyne was used at all. There was a steady 
diminution of pain from the first. The splint was removed 
on the twelfth day, and the electricity was stopped on the 
eighteenth day, when she was pronounced well. She has 
had no return of the attack since. 



342 GRAEME M. HAMMOND. 

Case III. — A German woman, aged about fifty, con- 
sulted me, in November, 1888, for sciatica of the left leg. 
She had had it for about ten days. It began as a slight 
pain in the sciatic nerve, which had gradually increased, 
until at the time I saw her it was very severe. She was 
confined to bed, and was evidently in great pain. I ascer- 
tained that she had suffered from chronic constipation for 
several years, and that, for the past few months, five or six 
days would pass without there being a movement of the 
bowels. She would then take a strong cathartic and relieve 
herself for the time being. When 1 saw her she had not 
had a movement for five days. She has no history of gout, 
rheumatism, or syphilis. I directed my attention to reliev- 
ing the bowels, supposing that when this was done the 
sciatica would disappear. It did disappear in a great 
measure, there being no pain at all as long as the patient 
remained quiet, but, almost as soon as she began to walk, 
the pain in the sciatic nerve would be felt, and would in- 
crease if exercise was persisted in. I confined her in bed 
for a week, not, however, using the splint or the ice-bags, 
and made applications of the continuous galvanic current 
twice daily. At the end of a week the patient could walk 
without the slightest pain. 

These three cases, though taken from a large number, 
are not selected cases, but represent fairly the general 
average. In cases of long standing, where continued in- 
flammation has produced organic changes in the nerve, 
with probable destruction of nerve-fibres, as shown by 
paralysis and atrophy of muscles, this form of treatment is 
not claimed to be efficacious. 



,: CEREBRAL SURGERY." 



From reports of the St. Louis Academy of Medicine, this 
department of surgery is not yielding very brilliant results. 
A patient with hemiplegia, aphasia, Jacksonian epilepsy, 
and otorrhoea was trephined on the supposition, that an 
abscess existed in the temporal lobe. The operation re- 
sulted fatally, and autopsy revealed three tumors in the 
central convolutions. Two other cases were reported where 
a correct diagnosis was made, but death followed the opera- 
tion in each. ("Medical Record," March 22, 1890). 



gert5C0jxe. 

By LOUISE FISKE-BRYSON, M. D. 

CHOREA AMONG THE INSANE. 
The "American Journal of the Medical Sciences" (April, 
1890) contains a paper on this subject by Theodore Diller, 
M.D., in which appear the following conclusions : 

I. There is to be found among the insane in hospitals 
and asylums in this country 1 choreic among each 425 of 
population. 

II. In all long-standing cases of chorea there is more or 
less marked tendency to mental deterioration, which, in 
many cases, progressively increases, and finally terminates 
in dementia, 

III. Many cases, even when there exists a considerable 
degree of mental impairment associated with chorea, enjoy 
fair physical health and apparently live almost as long as 
they would have done had they been free from the mental 
and nervous affection. 

IV. The proportion of male to female adults is about the 
same ratio as is found to exist between the sexes in children 
affected with acute chorea. 

V. The same causes that are known to produce chorea 
in children are found to operate in causing the disease in 
adults ; but, in the case of the latter, additional causes pecu- 
liar to adult life, such as apoplexy, anxiety, etc., are capable 
of producing the disease. 

VI. Persons of adult years are sometimes, though rarely, 
attacked while suffering from rheumatism — the disease being 
of about the same character as that commonly observed in 
children, but more likely to become chronic. 

VII. As to pathology, the following appear to be reason- 
able conclusions : (a) A number of cases arise from, and are 
caused directly or remotely by, an attack of rheumatism. 
(6) In the majority of cases, heart-disease is absent, and 
there is a negative history as to rheumatism, (r) Coarse 
lesions, acting as irritants to the motor cells of the brain or 
the tracts proceeding therefrom, are in some cases the prime 
cause. Such lesions most commonly are clots recent, organ- 
ized, or broken down. 

VIII. Chorea is found at all ages. 

IX. Persons may inherit the disease directly. 

X. The disease mav be congenital. 



344 PERISCOPE. 

XI. Chorea and epilepsy are intimately related to each 
other. Epileptic convulsion (Jacksonian) may be confined 
to a single member ; the same is true of choreic convulsions. 

DUBOISIA SULPHATE IN PUERPERAL MANIA. 

The " College and Clinical Record," January, 1890, states 
that Roberts Barthalow advises the subcutaneous injection 
of duboisia sulphate, gr. -^j to -g^-, in puerperal mania charac- 
terized by delusions and systematic depression. The indi- 
cation for atropia in epilepsy is depression; in the opposite 
condition, the bromides are indicated. 

MYXCEDEMA AND CO-EXISTING EXOPHTHALMIC GOITRE. 

In a critical review by P. Kovaleski of "Myxcedema or 
the Pachydermic Cachexia," contained in the "Archives de 
Neurologie," November, 1889, there is given an interesting 
history of this unfortunate combination. The patient, an 
only child, forty-six years old, had the poorest kind of a 
chance, in point of heredity. Her paternal grandfather 
was a drunkard, and died in an insane asylum. Her father 
committed suicide at the age of twenty-five, a victim to 
melancholia. The mother was an epileptic. At fourteen 
the patient talked and walked in her sleep, though strong 
and well during childhood. The girl married at eighteen, 
very unhappily. Three or four attacks of epilepsy a year 
{petit mal) began now to manifest themselves. At twenty- 
four, one attack was followed by automatic acts, such as 
attending to household affairs, going out, making purchases, 
of which she had no recollection. Once or twice a year this 
happened ; and when the woman was about thirty-two this 
psychic automatism became of longer duration, lasting 
eighteen hours, during which time she was irritable, quar- 
relsome and even violent. She had hallucinations, and 
moments of terrible anguish and anxiety. When forty 
years old, the patient left her husband, became poor and 
began to earn her own living. Periodic tachycardia now 
set in, and later became violent and continued. In two 
years, exophthalmia appeared ; and eighteen months after- 
ward, enlargement of the thyroid. She was sometimes 
better, sometimes worse, with frequent attacks of epileptic 
violence. During these attacks the symptoms of Basedow's 
disease were intensified, and became less pronounced when 
the seizures disappeared. The patientwascarefully examined 
during a paroxysm of epileptic violence, and the following 
conditions noticed : feet and legs swollen, from the ankles up 
to the knee ; skin stretched and dirty yellow in color, shining, 



periscope. 345 

and denuded of hair, cold and dry to the touch ; sebaceous 
and sudorific secretions absent. There was pitting or 
rather displacement on pressure, for the depression made 
by the finger disappeared when it was removed. The only 
heart symptom was acceleration of its beat (120-140). The 
urine was non-albuminous, of yellow tint, acid reaction, 
and containing a considerable quantity of urates (1015). 
Swelling similar to that in the feet existed in the cheeks 
and lips. The eyelids were much wrinkled, but not swol- 
len. Hair on the head had become thin, and there was 
none whatever in the axilla. These symptoms, together 
with poverty of blood, insomnia, hallucinations of sight and 
hearing, manifestations of fear and terror, complete "ab- 
sence," and a tendency to violence made up a picture of 
sufficientmisery. This was succeeded by tranquillity in about 
three days. But her peaceful condition was not one of 
quiet, not post-epileptic depression. There was confusion 
of mind, indistinctness of speech, indifference, loss of 
facial expression, and general stupidity. Warm baths, 
galvanism (subaural), quinquina, small doses of arsenic, and 
somewhat energetic treatment, slowly brought about im- 
provement. In three months all swelling had disappeared, 
and her psychic state became natural. What remained, 
however, were anaemic and exophthalmic goitre. 

The patient stated that five or six months previous to 
this last attack she began to be so weak, broken, and 
exhausted, that her only desire was to stay constantly in 
bed. Thinking was difficult, or, to be more exact, she had 
no desire to think. Physically, she was not ill. The tem- 
perature was subnormal, and weariness so great that walk- 
ing or working became almost impossible. She would sit 
down anywhere, thinking of nothing, and completely 
broken up. The swelling of the hands was not always 
present. Without known cause she lost eight teeth during 
the second month of her illness. Appetite and digestation 
remained good. There was no perspiration or oily secre- 
tion. The tongue became swollen, the saliva abundant, 
sticky, and thick. The patient always complained of feel- 
ing cold, especially in the parts that were swollen. There 
was but slight change in the thyroid gland at any time. It 
was a little larger during the epileptic delirium. 

TROPHO-NEUROSIS AS A FACTOR IN THE PHENOMENA OF 

SYPHILIS. 
The "St. Louis Courier of Medicine," Feb., 1890, calls 
attention to a paper with this title by Dr. G. Frank Lydston, 
in which the author affirms that syphilitic, as well as other 



346 PERISCOPE. 

fevers, are due the action of a specific poison upon the 
sympathetic, and that the syphilitic poison may produce 
disturbance of the sympathetic with perversion of tissue, 
of metabolism, and excessive production of heat. The in- 
constancy of the syphilitic fever is explicable on the ground 
of idiosyncrasy. The roseola is due to vaso-motor changes 
with dilatation of the capillaries. In pronounced syphilitic 
lesions, the accumulation of cells is an exaggeration of 
normal tissue-building that is presided over by the sympa- 
thetic. Syphlitic infection has a peculiar affinity for the 
nervous system, especially for the upper and cervical por- 
tion of the sympathetic. The proportion of lesions of the 
head, face and mouth is larger than other portions of the 
body, especially those parts supplied by the fifth cranial 
nerve. The affinity of the specific infection for the iris may 
be easily explained in view of its sympathetic distribution. 
Syphilis seemingly possesses the power of dissecting out 
definite portions of osseous tissue (apparently by cutting 
off their nutrient supply) in a manner as clearly as it can 
be done by the knife. The explanation of destruction by 
pressure of syphilitic exudate will not suffice in these cases. 
Carefully observed, it will be found that the first symptoms 
experienced by the patient are those incidental to the pres- 
ence of a foreign body, i.e„ dead bone in the tissues. If 
pressure were the cause of the necrosis, the death of the 
bone would be preceded by more or less painful swelling 
and inflammation. A perversion of trophic function in the 
nerve filaments supplying the parts is the only plausible 
explanation. All the pathological processes incidental 
to syphilis — whether the poison be microbe, degraded cell, 
or chronic abnormity — are due to disturbances of nutrition, 
resulting from the profound impressions made upon the 
sympathetic, 

Asylum 2totc5. 

By FRANK H. INGRAM. 
Dr. Charles W. Pilgrim, formerly an assistant at the 
Utica Asylum, has been appointed medical superintendent 
of Willard Asylum, to succeed Dr. P. M. Wise. Dr. Pilgrim, 
during his long experience with the insane, has gained 
an enviable reputation as a physician and an executive 
officer. 

Dr. Geo. F. M. Bond resigned the superintendency of 
the Ward's Island Asylum on March 10th, to enter general 
practice in this city. Dr. Bond's successor, Dr. William 



ASYLL 'M XO TES. 347 

Austin Macy, was assistant superintendent, and his recently- 
vacated position has been filled by the transfer of Dr. Lucius 
C Adamson from the Blackwell's Island Asylum. 

During the last few weeks the physicians at the Ward's 
Island Asylum have had served upon them numerous writs 
of habeas corpus. These writs were issued upon the appli- 
cation of a former asylum patient, who it would seem, has 
taken upon himself the task of attempting to liberate some 
dozens of men believed by him to be sane and unjustly con- 
fined. With a single exception, in which the jury's verdict 
•'sane" was scarcely in keeping with the evidence pre- 
sented, the patients were either remanded to the care of the 
asylum physicians or were discharged in custody of respon- 
sible friends. 

Dr. Dwight R. Burrell, resident physician of Brigham 
Hall, Canandaigua, N. Y., and Miss Clara E. Kent, of Kent- 
land, Ind., were married March 20th. 

We regret to learn that Dr. J. S. Dorsett, superintendent 
of the State Lunatic Asylum, Austin, Tex., was attacked 
and dangerously injured by a patient named McDermott. 
Dr. Dorsett was struck on the back of the head with an iron 
bar, and the assault was the outcome of a delusion which 
originated in the mind of McDermott at the time of the 
hanging of murderer McCoy, against whom the doctor tes- 
tified. This is another striking example of the dangers to 
which asylum physicians are particularly exposed. Since 
1875 several men prominent in the profession — notably Dr. 
Cook, of Canandaigua, Dr. Sawyer, of Providence, and Dr. 
Metcalfe, of Kingston, Ontario — have died at the hands of 
insane patients ; and the death of Dr. John P. Gray, of 
L'tica, was, in great measure, due to the bullet-wound in- 
flicted by an insane barber. 

Dr. Samuel B. Lyon, for several years identified with the 
management of Bloomingdale Asylum, in the capacity of 
assistant medical superintendent, has been formally ap- 
pointed medical superintendent, to fill the vacancy occa- 
sioned by the death of Dr. Charles H. Nichols The 
promotion of Dr. Lyon is a most deserving one, reflecting 
credit upon the institution and its board of governors. 

Dr. J. Elvin Courtney, formerly interne at Bloomingdale 
Asylum, has been appointed assistant physician to the 
Hudson River State Hospital, Poughkeepsie. 

Dr. Charles Gray Wagner has been promoted to the 
position of first assistant physician in the Utica Asylum, to 
succeed Dr. Pilgrim. 



348 ASYLUM XOTES. 

Dr. Wm. D. Granger, for eight years first assistant phy- 
sician at the State Asylum for the Insane, at Buffiilo, N. Y. 
opens a private institution for the insane at Mt. Vernon, 
near this city, on June 1st. Dr. Granger has created for 
himself not only a State, but a national reputation, through 
the important part he took in aiding Dr. J. B. Andrews to 
make the Buffalo asylum the model institution of this 
country, and by the wide dissemination of his " Handbook 
for Training Nurses upon the Insane," published some years 
ago by G. P. Putnam's Sons. He has purchased the Mas- 
terson estate, midway between Mt. Vernon and Bronxville, 
consisting of an elegant stone mansion, cottages and seven- 
teen acres of beautiful grounds upon the high ridge between 
the two towns. This institution will be the nearest to the 
city and most convenient of reach among those now in ex- 
istence. 

IJjeitr %VLstxumznts. 



AN IMPROVED CALORIMETER. 

By ISAAC OTT, M. D. 

THE great importance of the study of the heat produc- 
tion and heat dissipation of animals has made it 
necessary to perfect the heat-measuring instrument, 
usually called a calorimeter. This instrument may be either 
an air or water calorimeter. Without going into any histo- 
rical details, it is permissible to state that Rosenthal and 
Rubner have recently constructed two air calorimeters, 
which are held to be quite reliable. But as they require 
greater care in the management of them than water calori- 
meters, the latter have been extensively used. Of the water 
calorimeters, the old one of Despretz, and Du Long, and 
that of d'Arsonval, are the most important. In the Des- 
pretz and Du Long instrument the interior box of metal is 
submerged in the water, and through the water a serpentine 
coil runs to convey air to and from the inner box containing 
the animal. It is in the main the instrument that has been 
used in Germany and this country. D'Arsonval was the first 
to make the interior box immovable by fastening it to the 
outer wall of the water resevoir. He also made a door to 
close the opening into the animal chamber. It was an im- 
provemement upon the clumsy, time-wasting and inaccurate 
instrument of Du Long. It kept the temperature constant 
by means of the expansion and contraction of the mass of 
water regulating a gas burner. Whatever change of tem- 
perature in the animal must then be due to changes in the 



NEW INSTRUMENTS. 349 

tissues. It also had a serpentine coil for removing the air 
from the enclosure. I have used this calorimeter of d'Ar- 
sonval's, but in a manner not intended by its originator. 
The gas arrangement was dispensed with, and it was man- 
aged as other water calorimeters. Reichert has also con- 
structed a calorimeter where the interior box is arranged in 
an immovable manner by attaching its inner reservoir to 
the outer wall of the water chamber. 

That the animal may be quickly placed in the interior of 
the instrument he has inserted a plug into an opening of the 
instrument, in the place of a door. Otherwise it is essentially 
the instrument of Du Long. The error of Reichert's calori- 
meter is 8.75 per cent. In the improved calorimeter (Fig. 
1) I have taken the cylinder form of d'Arsonval and made 




several modifications. The agitator, 0, sits astride the inner 
cylinder, outside the leaden coils, and is run at the rate of 
sixty to seventy times a minute by means of a water motor, 
x. In other calorimeters, the water is occasionally agitated 
by a hand contrivance. Instead of the air entering the 
inner chamber in a straight tube, it traverses the tube H, 
coiled upon itself in the water reservoir of the instrument, 
and enters the enclosure at its base. The air emerges at 
the opening T at the top, and is carried out through the 
serpentine coil and through the aspirating meter M, which 
records at the same time the amount of air. The constant, 
activity of the agitator causes the water to equally diffuse 
the heat and to permit none to be given to the air. In the 
instrument of Reichet, nearly one-sixth of the heat is given 
to the air, and like all air calculations this is conducive to 
error. The door K, swings upon a hinge, and in its centre has 
a glass by which one can readily see the state of the animal 

At its edge it is lined 



or the apparatus connected with it. 



35° 



NE W INS TR UMENTS. 



with rubber and closed by powerful iron screw clamps. In 
front of the door is a mattress of saw-dust several inches 
thick. Over and around the calorimeter, instead of the 
usual saw-dust or felt, I used the packing material of wood 
fibre known as " Excelsior." The whole is enclosed in a 
square box, which has a door. The calorimeter is sixteen 
inches in length and twelve inches in diameter. At A is a 
circular opening, through which a thermometer, graduated 
to -jV of a degree Fahrenheit, passes into the water and 
enables one to easily read a hundredths of a degree. At B 
is an opening in the air tube for the air thermometer to be 
pushed in. 

The calorimeter is made up of the following parts: water, 
30.72 lbs.; iron, 17 lbs.; solder, 1.50 lbs.; lead, 51 lbs. By 
multiplying these with their "specific heats," there is ob- 
tained the number 34.32. 







Sp. heat. 






Water, 30.72 lbs. 


X 


1. 00 


= 


3O.72 


Iron, 17.00 " 


X 


.1138 


= 


I.9346 


Solder, '1.50 '" 


X 


.0789 


= 


O.II83 


Lead, 51.00 " 


X 


.O305O 


= 


1-5555 



343284 

34.32 = units of heat necessary to raise the calori- 
meter i° F. 

To test the instrument as to its accuracy, I used a tin 
vessel, closed on all sides except a small opening for the 
introduction of a thermometer and the heated water. This 
opening is closed by a metal screw-cap. When the weight 
and temperature of the water in this test-vessel are known, 
it is put in the calorimeter, and air aspirated through the 
calorimeter. Below is an experiment showing the method. 



R. T. means 
A. T. " 
C. T. " - 
E. T< " 
V. T. " - 
M. 



room temperature, 
air 

calorimeter " 
exit tube " 
tin vessel " 
meter " 



1 I ME. 

P. M. 


R. T. 


A. T. 


C. T. 


E. T. 


V. T. 


M. 


1.30 


73-7 




71.48 




93-7 


706447 


1.40 




73-4 




22.2C. 






!-5 




73-7 




22.3 






2.00 




73-4 




22.3 






2.10 




73-3 




22.4 






2.20 




73-6 




22.5 






2.30 


73-3 


73-3 


72.46 


25.6 


83.2 


7"°55 



BOOK REVIEWS. 



35< 



73-5 73-4 +.98 22.3 C C 10.5 4608 

i-oCorection 1-05 Correction 72.i4 F. Litres. 



72.5 72.35 



.35 Correction 



71.78 71.79 

.56 loss of temp, of air. 
Weight of tin vessel and water = 4.42. lbs. 
Weight of tin vessel = 1.3 

Water =3.12 

Heat lost by vessel of water = 33.85 
Heat accounted for by calorimeter = 32.02 
Error = 5.4 %. 

As is seen by the calculations the error is 5.4 %. 
I performed a half dozen experiments, and found the vari- 
ations from this number to be within a degree; hence, it is 
necessary to assume that it is an instrument of precision. 
For absolute accuracy the moisture of the air and the baro- 
metic correction should have been made, but they would 
not alter the result perceptibly. It was always used with 
the air a degree or so above the temperature of the calori- 
meter. The agitator was also set in motion for a half hour 
before the observation commenced. The room temperature 
for twenty-four hours previously was kept nearly the same. 
With these precautions the instrument works accurately. 
This instrument has been used during the past year in my 
laboratory. 

A Text-Book of Mental Diseases, with Special 
Reference to the Pathological Aspects of In- 
sanity. By W. Bevan Lewis, L.R.C.P. Philadelphia: 
P. Blakiston, Son & Co., 1890. 
We most cordially welcome Dr. Lewis' book. It treats of men- 
tal diseases from an elevated and new aspect, and bears throughout 
the stamp of research and originality; and it is of especial value, as 
it contains as well the product of years of practical experience. 

It is refreshing to find no quarreling over classifications, defini- 
tions of insanity, clinical romancing, or medico-legal inanities. It 
begins by a careful detail of the anatomical structure of the nervous 
system, especial attention being given to the cerebral cortex and the 
nerve-cells. 

Here and there throughout this first section the author directs 
the reader to the most important histological elements that play so 
important a role in the pathological changes of certain forms of 
/nsanity. 



35 2 



BOOK REVIEWS. 



Then follows a clinical section, based upon the analysis of four 
thousand cases of insanity treated at the West Riding Asylum, of 
which Dr. Lewis is medical director. 

This section is introduced by a psycho-physiological considera- 
tion of the siates of depression and exaltation. When scientists 
treat upon psychological subjects they become imbued with an idea 
that it is necessary to be abstruse, to coin picture- words; simple 
English descriptive phraseology gives way to "intellectual poten- 
tials" without " definite cohesion." 

The reviewer felt, while reading this section, that his education 
had been sadly neglected or his "'automatic segregation" was out 
of gear. But he had a "vivid realization" that very often sense 
was lacking and good English abused. 

There is a vast difference between this especial part and the rest 
of the work, as though written by some one else. It is unquestion- 
ably scientific, yet it is labored. 

In the truly clinical and pathological sections his descriptions 
are simple, instructive, and very interesting. The metaphysical 
would be also, if the author had not felt compelled to have written 
for Spencerian minds. 

It seems a duty for reviewers of books to find something to criti- 
cise. It is much easier, no doubt, to criticise psychological deduc- 
tions than to create them, but it is not fair to stamp " text-book" to 
this part of the work. We claim there should have been a few 
preparatory chapters and simple definitions and illustrations scattered 
here and there, to make the reading easier and the interpretation 
pla'n 

The pathological is most instructive, and well worthy the atten- 
tion of all scientists. 

The special subject of the " scavenger cell, " and its part in 
the history of lymphoidal connective-tissue formations, is well 
advanced. 

The question, Does the book fill all the conditions of a text- 
book? is hardly to be answered affirmatively. It seems to the 
reviewer to be, instead, directed to the physiologist, psychologist, 
and alienist. It is more than a text-book to the pabulum-searching 
student or the hurrying physician. 

It is certainly an admirable and instiuctive treatise on mental 
diseases. 

The Neuroses of the Genito-Urinary System in the 
Male, with Sterility and Impotence. By Dr. R. 
Ul.tzmann, Professor of Genito-Urinary Diseases in the 
University of Vienna. Translated by Gardner W. 
Allen, M.D., Surgeon in the Genito-Urinary Depart- 
ment, Boston Dispensary. Philadelphia and London : 
F. A. Davis. 
This excellent little volume, one of the "Physician's and 

Student's Ready Reference Series," will be welcome, not only to 



BOOK REVIEWS. 



353 



many an American practi ioner, who in his pilgrimage to Vienna 
was privileged to listen to the eloquent discourses of the late Prof. 
Ultzmann, but will also, as we feel assured, meet with a grateful 
reception by those not thus favored. 

Well versed in all branches of medicine, the author possessed 
the rare ability of interweaving clinical experiences with teachings 
gained from the study of microscopy, physiology, and pathology 
into a harmonious unity. Like other literary productions of Ultz- 
mann, the present work, which consists of a compilation of the two 
monographs, "Ueber dieNeuropathien des mannlichen Geschlechts- 
apparates '' and "Ueber Potentia generandi und Potentia coeundi," 
is eminently practical, yet scientific, and its style very fasci- 
nating. 

The chapter on Impotence and Sterility is especially well written, 
and, as the author's name alone would be a guarantee, is free from 
all charlatanism, which, unfortunately, cannot be claimed for some 
recent publications by otherwise reputable authors. The translation 
is excellent. We can conscientiously recommend the volume to 
every student and practitioner in search of knowledge on the topics 
therein contained. A. F. B. 



Spinal CONCUSSION : Surgically considered as a Cause of 
Spinal Injury, and neurologically restricted to a cer- 
tain Symptom Group, for which is suggested the Desig- 
nation EricJisens Disease, as One Form of the Traumatic 
Neuroses. By S. V. Clevenger, M.D. With thirty wood 
engravings. 8vo, pp. iv. to 359. Philadelphia and 
London, 1889 : F. A. Davis, Publisher. 

This work, attractive in size, form, binding, and impression, is 
of great interest to the neurologist as well as to the general practi- 
tioner in localities in which accidents frequently occur. While 
those of the latter category whose scientific training is incomplete 
may find some of the technicalities of the book a little beyond them, 
they will still find in this most recent expose of the subject so much 
that is helpful and even necessary to their success, that it becomes 
quasi-indispensable to them. 

The author imparts much of his originality to the work by his 
independent appreciation of the good and also of the indifferent 
endeavors of other authors on spinal concussion. On more than 
one page he likewise justly deplores the insufficiency of medical 
education in our country. Those interested in the progress of that 
most subtile and difficult specialty, neurology, will read with dis- 
couragement and, at the same time, admit the truth of the following 
lines from page 25 : " It is sad to reflect that the majority of medical 
men in our country have never seen a human spinal cord, would 
not recognize one if they did see it, nor would they know how to 
take it from its bony canal, and certainly would attempt to preserve 



354 BOOK RE VIE WS. 

it in alcohol instead of Miiller's fluid, and would be surprised to 
learn that alcohol would unfit it for microscopical examination." 

After reviewing Erichsen on spinal concussion, and Page on 
injuries of spine and spinal cord, our author sums up recent discus- 
sions on spinal concussion, in which the most noted neurologists of 
the present epoch are cited, as Leyden, Westphal, Erb, Oppenheim, 
Spitzka, Putnam, Dana, Hammond, Seguin, Bramwell, Knapp, and 
others. This is followed by a chapter on Oppenheim's important 
work on "Traumatic Neuroses." 

The chapter on the spinal column contains a summary of our 
latest knowledge of the anatomy and physiology of the spinal cord, 
and is accompanied by numerous plain and colored diagrams of 
great use in the study of this part of the body. It also contains 
many aphorisms of the highest importance pertaining to the pathol- 
ogy of the cord and of its membranes. 

The most practical part of the work resides in the four excellent 
chapters on the symptoms of Erichsen's disease (spinal concussion), 
on diagnosis, on electro diagnosis, and on differential diagnosis. 
They are elaborated in a masterly manner, and are full of the most 
necessary data for the practitioner, be he specialist or not. 

The most peculiar feature of the book is found in the chapter 
called "Pathology," but which should more appropriately be termed 
" Pathogeny," since it seeks to explain the cause and origin of the 
disease. Our author here develops the views, original with himself 
and "not heretofore advanced," which impute to injuries of the 
spinal sympathetic nervous system the preponderating role in the 
production of the varied symptoms embraced under the head of 
spinal concussion. That the sympathetic nervous system reacts 
upon the cord through vaso-motor nerves is not to be doubted and 
it is easy to admit that functional disturbance of the cord could 
result from traumatism of certain parts of that system. We are 
quite prepared to accept most of the propositions he sets forth in 
this chapter, supported as they are by experiments and opinions of 
numerous authorities in neurology. 

A few directions concerning treatment and some excellent medico- 
legal considerations form the conclusion of this very recommendable 
treatise, of which the many good points cause us to overlook the 
fact that some of its phrases are not specimens of the most classical 
English. W. W. S. 



BOOKS RECEIVED. 

Injuries and Diseases of Nerves, and their Surgi- 
cal Treatment. By Anthony A. Bowlby, F.R.C.S. 
Philadelphia: P. Blakiston, Son & Co., Publishers. 

A New Medical Dictionary including all the words and 
phrases used in medicine with their proper pronuncia- 
tion and definition. By George M. Gould, B.A..M.D.; 
P. Blakiston, Son & Co., Philadelphia : 1890. 



BOOK RE VIE WS. 355 

PAMPHLETS, ETC., RECEIVED. 

Sanitary Entombment.: The Ideal Disposition of 
the Dead. By the Rev. Chas. R. Treat. Reprint. 

The Vagus Treatment of Cholera, as exemplified in 
Returns from the Cholera Hospitals of Malta during 
the Epidemic of 1887. By Alexander Hackin, M.D., 
F.R.C.S. Reprint. 

Multiple Neuritis. By Irving D. Wiltrout, M.D. Re- 
print. 

Brain and Spinal Surgery in Philadelphia. By 
Irving D. Wiltrout, M.D. Reprint. 

An Experimental Study of Lesions arising from 
Severe Concussions. By B. A. Watson, A.M., M.D. 
Philadelphia, T890: P. Blakiston, Son & Co., Publishers, 

First Annual Report St. Bartholomew's Hospital 
and Dispensary. 84 Carmine St., New York. 

Tobacco Amblyopia. By Leartus Connor, A.M., M.D. 
Reprint. 

Sketch of the Late Dr. J. Edward Turner, the 
Founder of Inebriate Asylums. By Dr. T. D. 
Crothers. Reprint. 



iSUsceitantj. 



SULPHONAL AND CHLORALAMID. 

Daniel R. Brower, M.D. ("Medical News," April 19, 
1890) : " The medical profession to-day is more fortunate 
than ever before in the number of sleep-producing remedies. 
Sulphonal is a comparatively recent remedy of great value. 
It does not interfere with the digestion, the circulation, or 
the heart's action, as chloral, the bromides, and opium 
frequently do. We have also the still more recent remedy 
chloralamid. It has some advantage over sulphonal in that 
it acts more rapidly, and when dissolved in wine has but 
little taste. Sulphonal, on the contrary, probably by reason 
of its great insolubility, often acts slowly, its effects being 
more manifest the next day than on the evening of its 
administration. You can often administer either of these 
remedies without the patient's knowledge, as they have but 
little taste." 



356 MISCELLAN Y. 

H/EMOGLOBIN COMPOUND. 

The predigestion of foods has done much for the dietary 
of invalids and convalescents Trom acute disease or with 
anaemia and enfeebled digestion. 

It must be admitted, however, that many cases require 
frequently in devitalizing diseases some efficient method of 
rapid nutrition, capable of ready absorption without taxing 
the digestive functions, to combat the anaemia. 

This is furnished most naturally by the circulating me- 
dium itself — blood containing the elements of nutrition in 
assimilable form — and a preparation of bullock's blood, 
entitled Haemoglobin Compound, has been prepared, and is 
now marketed by Parke, Davis & Co. 

COMPLIMENTARY TO ONE OF OUR ELECTRICAL 
MANUFACTURERS. 

The Law Telephone Company have recently shipped 
eight of the " Law Galvanic Outfits" to Europe : three out- 
fits of 60 cells each going to Paris ; one to Boulogne ; one 
to Berlin ; two to London ; and the last to Dr. Lawson Tait, 
Birmingham. 

NEW WORDS. 

We have been invited by a large publishing-house, who are 
preparing to issue a Complete Dictionary of the English Language, 
to send in a list of new words that ought to, in our estimation, 
appear in it. 

Any words sent us will be gladly incorporated in a list to be sent 
them, and invite our readers to interest themselves in this important 
matter. 

NOTICE. 

They who read medical journals to the exclusion of the 
advertisements make a serious practical mistake. It is 
seldom that their perusal does not prompt the use of some 
forgotten remedy of value, reveals an address mislaid, or 
the superiority of some instrument. 

The journal's advertisements ARE GREAT REMINDERS. 

They make most journals a possibility, and it is cer- 
tainly an advertiser's due that their various notices shall 
be read. 

It is most urgently requested that the personal friends 
of this journal will aid its advertisers and endeavor to make 
them feel that their support is appreciated. 

Wanted. — Complete file of Journal of Nervous and 
Mental DISEASE, bound or unbound, to 1888. Special 
numbers wanted : January, 1888; March, 1889. 



VOL. XV June, 1890. No. 6 

THE 

Journal 

OF 

Nervous and Mental Disease. 



©triatrial Jtrticlcs. 



THE MINUTE STRUCTURE OF THE GRAY 
NERVE-TISSUE. 

By C. HEITZMANN, M.D. 

IN the year 1873 1 I made the following statements with 
regard to the structure-elements of the nervous sys- 
tem : Thin sections from the cortex or the main 
ganglia of a recently killed grown rabbit are the best 
specimens for examination with high powers of the micro- 
scope. The section may be transferred to the slide with 
or without the addition of a preserving fluid ; in the former 
instance a very dilute solution of bichromate of potash is 
preferable, because, as proved by A. Rollet, this does not 
alter the structure of protoplasm. Layers of protoplasm, 
with numerous formations like nuclei, ganglion-corpuscles 
of varying shapes, and medullated nerve-fibres of different 
sizes are seen. The living matter in the formations termed 
nucleoli, being compactly accumulated, is homogeneous 
and has a yellowish lustre ; while in the protoplasma of all 
structure-elements of the nervous system the living matter 
is distributed in thin layers in the shape of granules and 
lumps, and is of an opaque gray color. All granules and 
lumps of the living matter are interconnected by means of 
delicate radiating spokes. 

1 Untersuchungen iiber das Protoplasma. Sitzungsber. d . Akad. d. Wissens 
in Wien. 



358 C. HEITZMANN. 

In that article I first announced that all constituent ele- 
ments of the gray nerve-tissue are constructed like proto- 
plasm in general, viz., of a reticulum of living matter, the 
meshes of which contain a lifeless nitrogenous liquid. My 
illustrations plainly show this' reticulum, both in the scat- 
tered nuclei, in the ganglionic corpuscles, and in the gray 
substance at large, the reticulum of the latter being uninter- 
ruptedly connected with that of the former. 

The first observer, who maintained the presence of a 
delicate reticulum throughout the gray substance, more 
especially that of the spinal cord, was Gerlach, in 1870. 2 
Since he was able to trace the filaments of this reticulum to 
the ganglion-cells, nay, their direct transition into the bodies 
of these corpuscles, he, apparently, was right in claiming 
that the reticulum itself was nerve-tissue. This assertion, 
however, was contradictory to the well-established doctrine 
in physiology that all nerve-conduction is insulated. How 
could there be any insulation of nerve-impulses, if these 
were to run through a nervous network pervading the gray 
substance as a whole ? While Gerlach's observation was 
admitted to be correct, his claim of the nervous nature of 
the delicate network has been doubted and overthrown by 
many excellent observers. Golgi, in 1873 3 and 1886, 4 
asserted that he was able to trace the filaments of the net- 
work to the ganglionic as well as to the connective tissue 
or glia-corpuscles, and, consequently, admitted the correct- 
ness of Gerlach's hypothesis in its essential features. At 
the same time he endeavors to draw a distinction between 
a purely nervous and a purely connective-tissue reticulum, 
denying the nervous nature of the broad or Deiters' off- 
shoots. 

S. Strieker, in 1883, s thoroughly discusses the nature ot 
the reticulum under question, pointing also to the broad 
offshoots of the ganglion-corpuscles, which were discovered 
by O. Deiters (1865), and termed by him "protoplasmic 

2 Art. Rti:kenmark. Strieker's Handbuch d. Lehre von den Geweben. 

3 Tulla struttura u. sostan. grigia. Comiuunic. prev. Milano. 

* Tulla fina anatomia degli org. centrali d. sistema nervoso. Milano. 

* Vorlesungen iiber allg. u. exper. Pathologic W'ien. 



MINUTE STRUCTURE OF GRAY NERVE-TISSUE. 359 

offshoots," the nature of which has remained entirely unset- 
tled, since they could not be proved to become nerves, or 
axis-cylinders proper. Have we any right, Strieker argues, 
to call offshoots nervous, simply because they are in union 




Fig. I. — Gray Nerve-tissue of the Spinal Cord of a Rabbit. Magn. = 1200. 
G Tripolar ganglionic corpuscle. A Axis-cylinder offshoot. R R Reticulum 
of living matter. N Neucleus forming point or intersection in the reticulum. 



with ganglion-corpuscles ? A similar reticulum exists in 
the outermost layer of the cortex of the brain, which lacks 
ganglion-corpuscles altogether, whose nervous nature had 
already been doubted by Meynert, and which nevertheless 
is continuous with the network of the deeper layers, so 
profusely supplied with ganglion-corpuscles. According 



360 C. HEITZMANN. 

to Strieker, the meshes of the network are filled with a 
finely granular substance, rendered conspicuous by certain 
reagents to such an extent that the reticulum itself becomes 
concealed by it. This filling may furnish the gray sub- 
stance with its peculiar consistency. Strieker considers the 
whole gray substance as inert, kindred to connective tissue, 
and considers nerve-action as existing only in the ganglion- 
corpuscles. 

A. Forel, 6 while admitting the correctness of Golgi's 
assertions, disagrees with this observer in regard to the 
central sensitive corpuscles. He says that all the sensitive 
nerves terminate in the reticulum of the gray substance 
without special centres. Kolliker (1887) is opposed to the 
assertion of Golgi, that the protoplasmic offshoots of the 
ganglion-corpuscles are not nervous in nature. 

I have thus briefly given the most important literature 
on this topic in order to show that the minds of histologists 
are still unsettled concerning the nature of the reticulum, 
which so profusely traverses and builds up the gray sub- 
stance. Not only do some observers deny it all activity, 
but Kuhne and Ewald (1877) have even demonstrated a 
good deal of the reticulum to be keratoid, horny, not being 
digestible in pepsin and trypsin. 

Fig 1 gives an accurate representation of the morphol- 
ogy of the reticulum. The drawing is made from a specimen 
of the spinal cord of a rabbit, which was treated with osmic 
acid, cut with the microtome, and then stained with alum- 
carmine. We see that the reticulum in some portions is 
extremely minute, scarcely discernible with the excellent 
immersion-lens of Tolles, at my disposal, while in other 
portions it encloses somewhat larger meshes, which, to a 
certain extent, may have been produced artificially by the 
cutting and mounting procedures. The reticulum is con- 
tinuous with that of the ganglionic corpuscle and that of the 
axis-cylinders. We can trace it to the walls of the capil- 
lary blood-vessels, where it traverses the narrow, peri- 

8 Einige hirnanatom. Betrachtungen u. Ergebnisse. Arch. f. Psychiatrie, 



MINUTE STRUCTURE OF GRA Y NERVE-TISSUE. 36 1 

vascular space, the same as it traverses the periganglionic 
space. 

According to my views the gray substance is constructed 
in the same manner as protoplasm in general, i. e. y by a 
reticulum of living or contractile matter and a liquid filling 
the meshes of the reticulum. The structure of the gray 
substance is identical with that of the ganglionic corpuscles 
and the scattered, apparently isolated nuclei : the only 
difference being that in the gray substance the reticulum of 
the living matter is extremely thin and delicate ; in the 
central form -elements, on the contrary, comparatively 
coarse and dense. Besides, there may be a difference in 
the chemical constitution of the filling liquid, which differ- 
ence, however, is not perceptible to the microscopist. We 
have neither any right to call the reticulum nervous, in the 
sense of Gerlach. nor inert or connective tissue, as claimed 
by other authors. 

In looking over the main varieties of connective tissue, 
i. e., the myxomatous, the fibrous, the cartilaginous, and 
the bony, we find as the most characteristic feature the so- 
called basis-substance. This is greatly at variance in its 
chemical constitution, even in apparently kindred forms of 
connective tissue. In one essential point, however, it is 
alike in all forms, viz., in filling the meshes of the reticulum 
and rendering it more or less consistent. The reticulum is 
concealed by the basis substance, and even in the myxoma- 
tous tissue never as plain as it appears in the gray nerve- 
tissue. It may be rendered conspicuous by different reagents, 
such as absolute alcohol, osmic acid, chloride of gold, etc. 
In the gray nerve-tissue such a basis-substance, the most 
important feature of connective tissue, is present only at the 
boundary-zone between the white and the gray substance 
(see Fig. 2, g), and in scanty bundles of a delicate fibrous 
connective tissue, which penetrate the gray from the white 
substance and run a radiating course through the former. 
At the boundary-zone the broad bundles of the interstitial 
inner perineurium rapidly decrease in bulk, for a short dis- 
tance retaining a striated or fibrous structure, and soon 
splitting up into fibres which assist in building up the 



362 C. HEITZMANN. 

reticulum. As long as the striated structure of bundles is 
recognizable, we have no reason to doubt the connective- 
tissue nature of the network. As soon, however, as the 
basis-substance proper is lost, the reticulum of living mat- 
ter, traversing the basis-substance, is freed. Single granular 
fibrillae, ever so conspicuously arising from the trabecular 
of the perineurium, are certainly not entitled to the name 
of connective tissue. Some of them may have undergone 
peculiar chemical changes (according to Kiihne and Ewald, 
keratoid or horny), and thus serve as a supporting apparatus 
for the delicate reticulum ; but they have ceased to be con- 
nective tissue. Where one ends and the other begins, the 
morphologist will never be able to tell. 

Scanty bundles of fibrous connective tissue emanate 
from the pia-mater offshoots, which are likewise instru- 
mental in constructing the inner prineurium and traverse 
the gray substance, as before mentioned, in a radiating 
direction. Probably they inosculate with the connective- 
tissue layer surrounding the ciliated epithelia of the central 
canal, although from personal observation I am unable to 
make such a statement positively. These bundles, being 
pierced by a reticulum of living matter, as all varieties of 
connective tissue are, profusely connect with the reticulum 
of the gray tissue, and again we are at a loss to tell at 
which point the basis-substance ceases and the living net- 
work has become free. 

Unless chemical micro-reagents will be found, far more 
delicate than are at our disposal at the present time, I con- 
sider the task, to accurately discriminate in the gray nerve- 
tissue between fibrous connective tissue and fibrillae of 
living matter, a hopeless one. What Strieker has claimed 
to be a granular filling mass is nothing but the most deli- 
cate portion of the reticulum itself, as evinced by the study 
of thin slabs with good immersion-lenses. 

The reticulum, certainly in its main bulk, is alive during 
the life of the organism, and by its contractions causes that 
which we call nervous impulse. The reticulum of the gray 
substance is able to conduct in essentially the same manner, 
as that of the ganglionic corpuscles, by contraction, which 



MINUTE STRUCTURE OF GRAY NERVE-TISSUE. 363 

means narrowing of the reticulum and expansion, viz., 
widening of the reticulum. The effect will, however, be 
different in the widespread, loosely arranged, and extremely 
delicate network of the gray tissue and the dense, compact 
one of the ganglionic corpuscles. Both being identical in 
their nature, the final result may depend merely on the 
anatomical differences in the distribution and compactness. 
Any living lump of protoplasm is, as is acknowledged to 
day, movable and sensitive without a trace of nerves. The 
amceba creeps and evades obstacles in its way, it perceives 
the light, though it is built up by nothing but a reticulum 
of living matter, without differentiation into nerves or nerve- 
centres. Looking at the structure of the gray substance in 
this light, all difficulties in explaining its histological nature 
will fade away, and nerve-action becomes explicable. The 
absolute insulation of nerve-impulse is, consequently, done 
away with, and numerous physiological and pathological 
observations strongly point toward the absence of a perfect 
insulation within the nerve-centres. 

The second topic under consideration is the structure of 
the axis-cylinder. This term includes the non-medullated 
nerve-fibres as well as the initial portions of the medul- 
lated nerve-fibres as yet destitute of a medullary invest- 
ment. 

Max Schultze, in 1868, : was the first to assert that the 
axis-cylinders have, in many instances, a fibrillated struc- 
ture which he claimed to be continuous with the fibrillated 
structure within the ganglionic corpuscles. S. Strieker, in 
1883,' admits that he saw the convincing specimens of Max 
Schultze, but at the same time declares that he was never 
able to see the fibrillated structure of the axis-cylinders in 
specimens of brains that were brought into hardening liquids 
immediately after the death of the animal. What the 
structure of the axis-cylinder is, this author does not say. 
I made the following statement in 1883 : 9 "With high am- 

7 Die Structurelemente des Nervensystems. Handbuch d. Lehre von den 
Geweben, von S. Strieker. 

- Vorlesungen iiber allg. u. exper. Pathologie, p. 576. 
" Microscopical Morphology, p. 298. New York. 



364 c - HEITZMAXX. 

plifications of the microscope, some of the larger non- 
medullated nerve-fibres distinctly show a delicate reticular 
structure ; others exhibit a number of minute vacuoles in 
their interior ; still others, and these are the finest nerve- 
fibres, have a homogeneous appearance and give no evi- 
dence of structure." On page 309 I publish a diagram of 
nerve-conduction, in which the axis-cylinders, as well as 
the ganglionic corpuscles themselves, are drawn reticular 
throughout. Should A. Forel's above-quoted views be 
correct, the presence of a sensitive nerve-ganglion will 
prove to be a fallacy, but would have to be replaced by a 
reticulum of living matter within the gray substance, into 
which also the broad or Deiters' offshoot ought to inoscu- 
late. That much plainly follows from my diagram, that I 
consider the structure of the axis-cylinder identical with 
that of the ganglionic corpuscles, viz., made up of a reticu- 
lum of living or contractile matter, much more delicate and 
dense in the axis-cylinders than in the ganglionic cor- 
puscles. In the latter elements this structure is scarcely a 
subject of doubt, and since it was first discovered by C. 
Frommann (in 1867) has oftentimes been described and 
illustrated by excellent histologists ; whereas the reticular 
structure of the axis-cylinder, at least as far as I know, was 
corroborated only quite recently by Max Joseph (1888). 10 
This observer has investigated the electric nerve-fibres of 
torpedo marm. He denies the keratoid or horny nature of 
the network within the myelin investment of the medullated 
nerves, since, contrary to the claim of Kuhne-Ewald, it is 
dissolved by pepsin and trypsin, and demonstrates the 
presence of a much more delicate network in the axis- 
cylinder. 

The question now arises : How was it possible that Max 
Schultze, one of our most skilled observers in microscopy, 
could have seen a fibrillated structure in the axis-cylinders ? 
For nobody will doubt that such a structure was visible, if 
so asserted by M. Schultze. There is but one explanation 
to this strange fact, viz., the faulty method of teasing nerve- 



,n Berliner Akademie-Bericht, p. 1321. Quoted from Edw. Klebs, Allg 
Pathologic II. Theil, 1889. 



MIXUTE STRUCTURE OF GRAY XERVE TISSUE. 



t6s 



specimens and their mounting in Canada balsam. We can 
realize that by dragging delicate structures, such as those 
of ganglion-corpuscles and axis-cylinders are, the reticulum 
will be drawn out and be artificially transformed into a 
series of fibrillar At first teasing was done by M. Schukze 
in an indifferent liquid, the iodine-serum, and afterward, .or 
fixation, alcohol and osmic-acid solution were resorted to. 
Fortunately, nowadays, all mutilating methods, such as 




Fig. II. — Boundary zone between the Gray and White Nerve-Tissue. Spinal 
Cord of a Rabbit. Transverse section. Magn. = I2CO. G Gray nei ve-tis;ue. 
IV White nerve-tis-sue. A Axis- cylinder. P Perineurium. 



tearing and teasing unquestionably are, have fallen into 
discredit, and find application only by narrow-minded 
histologists, who are unable to appreciate the sad conse- 
quences of mechanical injuries and of laceration of tissues, 
the structure of which becomes comprehensible only by a 
strict conservation of integrity and continuity. 

Since 1873 I have been convinced of the reticular struc- 
ture of all nerve-elements to such an extent that I consid- 
ered the ultimate axis-fibrillae — composed of granules and a 
single inter-connecting thread, rendering these fibres rosary- 
like — merely a linear projection of the reticulum, inosculat- 
ing with the living matter, both at the periphery and in the 
central gray tissue. To-day I have no reason to change 
my views, after having studied a number of specimens, 



366 C HEITZMANN. 

treated with widely different methods. Fig. 1 shows the 
delicate reticular structure in the axis-cylinder running 
longitudinally; Fig. 2, the transverse sections of these 
formations within the white mantel of the spinal cord. 

Fig. 2 represents the boundary-zone between the white 
and gray substance, in the transverse section of the spinal 
cord of a rabbit. The specimen was treated first with osmic 
acid and afterward with alum-carmine solution. It is strik- 
ing that the osmic acid did not stain the myeline in a dark- 
brown color, but the interstitial inner perineurium, the 
transition of which into the reticulum of the gray tissue is 
well shown. The axis-cylinders plainly exhibit a finely 
reticular structure. Around them we recognize a delicate 
sheath, the axis-cylinder sheath of L. Mauthner, and at the 
periphery of the fibre the sheath of Schwann, enclosing the 
myeline. Besides, here and there are visible other concen- 
trically arranged layers, the significance of which I am 
unable to tell." The space, previously occupied by the 
myeline, is traversed by a knotty, irregular network, first 
described by Kuhne and Ewald in 1886, 11 and claimed to be 
keratoid or horny by these observers, owing to the fact that 
it remains undigested under the influence of pepsin and 
trypsin. 

In the finest axis-cylinders I am unable to discover any 
structure whatever, which does not exclude the possibility 
of a structure becoming recognizable, at some future time, 
by improved optical or staining appliances. 

The presence of a contractile reticulum within the axis- 
cylinder would enable us to endeavor reducing nervous 
action to contractility, a feature found in all protoplasmic 
formations. The denser and more delicate the reticulum 
of living matter, the more rapid will be its contraction, 
furnishing the physiological basis of all nervous impulse. 
Centripetal contraction will be felt as sensation; centrifugal 
will result in motion. The nerves, when viewed in this 
light, merely convey rapid contractions. They may be 
considered as an apparatus of refinement of physiological 

11 Verhandl. d. Heidelberger Geseilsch. 



MINUTE STRUCTURE OF GRAY NERVE-TISSUE. 367 

properties, common to every living lump of protoplasm, 
animal as well as vegetable, i. e., sensation and motion. 

The third and last topic of my paper is the origin of 
axis-cylinders, or nerve-fibres, from the reticulum of the 
gray substance. 

O. Deiters, in 1865, 1: made the assertion that from a gan- 
glionic corpuscle, the number of its offshoots being ever so 
large, probably but one offshoot arises which is a true 
axis-cylinder, and which, coursing toward the periphery, 
respectively the white substance of the brain and spinal 
cord, becomes a nerve proper. Since that time this fact is 
generally admitted as correct. Deiters called all the other 
offshoots protoplasmic or branching. J. Gerlach, the dis- 
coverer of the nervous reticulum in the gray substance, in 
1870 13 first made the statement that Deiters' offshoots inos- 
culate with the nerve-reticulum, and true axis-cylinders 
originate from this reticulum, not being in direct union with 
any ganglionic corpuscle. His description of the method 
best suited for the demonstration of this fact is briefly as 
follows : " A perfectly fresh, yet warm spinal cord of a calf 
or ox is sliced with the razor into very thin longitudinal 
sections, best through the anterior horns, and immediately 
placed into a very dilute solution of bichromate of ammonia 
(1 to 5,000 or 10,000 water) for two or three days. After 
this the slabs are placed into dilute ammoniacal carmine, 
and, after twenty-four hours, are torn up by means of 
needles, with special care for the preservation of the dark- 
red nerve-cells. Such specimens are preserved in gly- 
cerin, or, preferably, allowed to dry, and, after addition 
of a minute quantity of oil of cloves, mounted in Canada 
balsam." 

I have purposely quoted Gerlach's words, in order to 
show that his assertions were based upon the study of 
teased specimens, as is also illustrated by his Fig. 223, 
the object of which is to demonstrate the origin of a branch- 
ing nerve-fibre from the nerve-reticulum. Xo wonder, 

1S Untersuchungen iiber Gehirn u. Riickenmark. 

13 Art. Riickenmark. Handbuch der Lehre von den Geweben, von S. 
Strieker. 



3 68 



C. HEITZMAXX. 



therefore, that but little attention was paid to Gerlach's 
statement, which, nevertheless, is perfectly true. 

In my " Microscopical Morphology" (1883), on page 288, 
I quote Gerlach's discovery, as follows : " The offshoots of 
the ganglionic elements are of two kinds: the broad, so- 
called protoplasmic offshoots of Deiters, and the narrow, 




Fig. TIL — Origin of Nerve-Fibres from the reticulum of living matter. Gray 
Nerve-tissue of the Spinal Coid of a Rabbit. Magn. = 1200. N N Bundles of 
nerve-fibres. RR Reticulum of living matter. 



axis-cylinder offshoots. Of the former we know that they 
connect neighboring elements, and branch out into the gray 
substance, where they divide into an extremely delicate 
reticulum, first described by J. Gerlach. This author fur- 
ther asserts that the ganglionic elements of Clarke's columns, 



MINUTE STRUCTURE OF GRAY AERVE-T/SSUE. 369 

and perhaps those of the posterior horns also, have no other 
than branching offshoots." On page 290: "According to 
Gerlach, it is also probable that irom the reticulum of the 
posterior horn nerve-fibres originate, which in this horn 
and in the white substance take a centripetal course." On 
page 288 I make the following assertion, independently of 
Gerlach and based upon observation of sections of the spinal 
cord, carefully preserved in their continuity: "Axis-cylinder 
offshoots arise also from the gray substance, without any 
connection with ganglionic elements." This statement is a 
corroboration of that of Gerlach. 

In order to show how such a statement could be made 
from the study of a sliced specimen, I affix Fig. 3, obtained 
from a spinal cord first treated with a one-per-cent. osmic- 
acid solution and afterward with alum-carmine. 

We see the reticulum — the region is that of the anterior 
commissure branching into the gray tissue of the anterior 
horn — condensed into filaments, which, gradually assuming 
an increasing diameter, are traceable a great distance into 
the gray tissue, and have no other connections with the 
adjacent reticulum but the delicate lateral spokes visible on 
axis-cylinders generally, including those that plainly arise 
from a ganglionic corpuscle. Can there be any doubt 
as to the nervous nature of such filaments ? I should think 
not. 

In the posterior horns there are no ganglionic corpuscles 
proper ; only formations like nuclei, which, in my convic- 
tion, serve as central formations, since in the brain of the 
lowest vertebrates they are the only elements visible in the 
gray tissue. My teacher, E. Brucke, often asserted that 
nobody has as yet been able to see nerve-fibres emanate 
from such nuclei in the posterior horns, and Gerlach's state- 
ment, that all sensitive nerves of the posterior horn inoscu- 
late with the reticulum of the gray tissue, is certainly cor- 
rect. In 1883, while in Paris, L. Ranvier, the ablest French 
histologist, was kind enough to show me what he consid- 
ered glia-cells, therefore connective-tissue elements, freely 
branching into innumerable offshoots and producing around 
the "cell" a delicate network. Golgi {loc. cit.) made at- 



37o 



C. HEITZMAXX. 



tempts to discriminate between a nervous and a connective- 
tissue reticulum, but failed to convince the histologists, since 
the differences in the taking up of certain coloring matters 
are altogether too slight. What an embarrassment, if the 
whole reticulum should be connective tissue, or horny 
material inert! Deiters' offshoots branch into it and axis- 
cylinders arise from it. Where are we to locate the centres 
of the sensitive nerves, if these inosculate with a connective- 
tissue reticulum ? 

There is but one way to escape all these difficulties, and 
this is to consider the reticulum as neither nervous nor con- 
nective tissue, but living or contractile matter. With this 
view an indirect connection is established between all cen- 
tral elements of the gray tissue, the nuclei, and the gan- 
glionic corpuscles ; though, I admit, the theory of a perfect 
insulation is lost. Similar formations we meet with in the 
retina, and there is no end of quarrels as to the nervous or 
connective -tissue nature of a number of filaments and 
reticular formations. Here, too, all difficulties could be 
overcome by simply admitting that the reticulum is living 
or contractile matter. 

Quite recently an important confirmation of Gerlach's 
original assertion has been made by Bela Haller (1886). 14 
This author demonstrated, in the ganglia of molluscs, mar- 
ginal ganglionic corpuscles and a reticulum emanating from 
them. Some of the offshoots of the latter directly become 
nerve-fibres, whereas the majority of the nerve-fibres origi- 
nate from the reticulum. Thus we are positive of a double 
origin of nerve-fibres. L. Edinger 15 is thoroughly convinced 
of this view, and we have good reasons to accept an excel- 
lent observer's coincidence with facts so much in harmony 
with the most advanced modern biological views. 

More and more we approach the doctrine, first estab- 
lished by myself in 1873, which claims that the living matter 
is continuous throughout the whole animal organism. The 

14 Untersuchungen uber marine Rhipidoglossen : II. Textur des Central- 
nervensystems. Morphol. Jahrb., XI. 

15 Schmidt's Jahrbucher, Jahrgang 1887, No. 8. 



MJNUTE STRUCTURE OF GRAY XERVE-TISSUE. 3 ji 

apparently well-founded cell-theory must be sacrificed in 
order to obtain a plain understanding, not only of the action 
of nerve-tissue, but of the whole organism. The nerve- 
tissue is long since acknowledged to be continuous through- 
out the body: it will take but one step further to establish 
the continuity and life of all tissues constituting the animal 
and. vegetable body. 

In the United States the progress of the novel views, 
which are not the worse for being dubbed by the late 
L. Elsberg the " bioplasson-theory," is slow but steady. 
Charles F. Cox, in an excellent presidential address, de- 
livered before the New York Microscopical Society, on 
January 3, 1890, expresses this progress in the following 
manner : 

"I can well remember, as perhaps you also can, the 
disgusted incredulity with which this new doccrine was 
received — an incredulity in which, I confess, I then shared. 
I am not sure that the appearance of a reticulum in the 
prepared blood-corpuscle is even yet generally accepted as 
evidence of a normal structure of the kind claimed by Dr. 
Heitzmann ; but the claim certainly gains support from the 
fact that vegetable histologists are pretty well agreed that 
a more or less similar reticulum is demonstrable in the 
protoplasm of plants. Prof. Goodale seems to have no 
doubt on this point. . . . 

" In the work from which I have just quoted, 16 Dr. Heitz- 
mann generalizes as follows : ' What . . . was called a struc- 
tureless, elementary organism, a " cell," I have demonstrated 
to consist only in part of living matter, while even the 
minutest granules of this matter are endowed with manifes- 
tations of life. The cell of the authors, therefore, is not an 
elementary, but a rather complicated, organism, of which 
small detached portions will exhibit amoeboid motions. . . . 
How complicated the structure of a minute particle of living 
matter may be, we can hardly imagine ; what we do know 
is that the so-called " cell " is composed of innumerable 
particles of living matter, every one of which is endowed 
with properties formerly attributed to the cell-organism. 

16 Microscopical Morphology. New York, 1883. 



372 



C. HEITZMAXX. 



" It having been shown that life hangs upon a web of 
infinite tenuity, and does not reside necessarily in either a 
vesicle or a lump, it was a natural and easy step to extend 
this network from tissue to tissue and organ to organ, in an 
unbroken circuit of vital communication. This step Dr. 
Heitzmann does not hesitate to take; for, says'he, ' there 
is no such thing as an isolated, individual cell in the tissues, 
as all cells prove to be joined throughout the organism, thus 
rendering the body in toto an individual. What was for- 
merly thought to be a cell, is, in the present view, a node 
of a reticulum traversing the tissue. . . . The living mat- 
ter of the tissues exists mainly in the reticular stage, and 
is inter-connected without interruption throughout the 
body. 

" Again, this at first very strange and, for some reason 
or another, unwelcome doctrine receives support from the 
investigations of botanists ; for, as Prof. Goodale remarks, 
this protoplasmic inter-communication between adjoining 
cells ' has been shown to be so widely true in the case of 
the plants hitherto investigated, that the generalization has 
been ventured on that all the protoplasm throughout the 
plant is continuous.' The position to which we have traced 
this matter is, then, that to the latest biology, in any par- 
ticular organism, a generally diffused and inter-connected 
substance, simple only in appearance under present optical 
aids, has taken place of the circumscribed, more or less 
isolated and independent, and recognizably complex vesicle 
which was the physical basis of life to the science of fifty 
years ago. In the words of Dr. Heitzmann: ' According 
to the former view, the body is composed of colonies of 
amoebae ; according to the latter, the body is composed of 
one complex amoeba.' " 

Truth is welcome, from whatever quarters it may come. 
In the support of the recent views the botanists have proved 
to be superior to animal biologists. Still, the plants have 
no central nerve-organs, no nerves. How much plainer is 
the truth evinced by an unbiased study of the structure of 
the gray nerve-tissue ! 






HYSTERICAL FEVER. 1 

By MARY PUTNAM JACOBI, M. D. 

CASE M. M. — The illness to be described began on 
Jul) r 22d last, 1889, when the patient entered the 
New York Infirmary. But in the preceding year, 
winter of 1 887-1 888, she had suffered from a succession of 
disorders, to which reference must be made on account of 
their bearing on the illness in question. 

In December, 1887, the patient was seized with a pain in the 
chest, unaccompanied by fever, but which was diagnosed 
pleurisy by the first physician consulted. His diagnosis had 
greatly alarmed the patient, As however, my own examina- 
tion of the chest failed to discover any physical sign of pleu- 
risy, I interpreted the pain as a pleurodynia. After this diag- 
nosis, the pain rapidly subsided ; but a paresis of the bladder, 
which had already showed itself, deepened to a complete 
paralysis and retention of urine. Catheterism was per- 
formed for some time, but the trouble finally yielded to 
strychnine and local faradization. There appeared severe 
pain in the left ovarian region, attended with fever. The 
temperature rose and fell irregularly through the day, occa- 
sionally going as high as 103°, more often reaching no 
higher maximum than 102' Physical examination of the 
pelvic organs failed to discover any objective sign of local 
inflammation, and the disease finally subsided. Before the 
patient had left her room, however, she was attacked with 
a severe catarrhal sore throat, attended with abundant 
diffuse mucous exudation, but not truly diphtheritic. This 
was in March. After recovery and resumption of ordinary 
occupations, the patient became subject to intermenstrual 
•metrorrhagia, for which no uterine cause could be ascer- 
tained, and which was referred to one of the obscure forms 
of functional ovarian irritation. During the summer of the 

1 Read at the Neurological Section of the Academy of Medicine, April, 1890. 



3 74 MAR Y PUTNAM JACOB/. 

same year (1888), the patient suffered from a bilateral 
partial paralysis of the lower extremities, especially affect- 
ing the peroneal muscles. She remained able to move her 
limbs in bed, but was quite unable to stand or walk. She 
recovered this power, however, when provided with braces 
which supported the ankles and reaching to the knees. 
She then went to the seashore, and for two or three months 
was perfectly well. On returning to the city and becoming 
involved in much mental worry and anxiety, her physical 
troubles returned. There were first, attacks of retention of 
urine and metrorrhagia ; then almost entire inability to use 
the eyes in reading, which a competent oculist explained 
by simultaneous paresis of several external ocular muscles. 
He referred this, moreover to an attack of diphtheria which 
had been experienced five years before ; but I think this 
was improbable, as, until the period which I have just 
described, the use of the eyes had been attended by no 
difficulty. It seems to me that the paresis was of an 
hysterical nature and analogous to that of the peroneal 
muscles, which had deprived the patient for a time of the 
power of walking. This opinion was subsequently also 
expressed by Dr. Putnam, of Boston. The ocular defect 
persisted through the winter. Twice during this time the 
patient was seized with an attack of severe pain in the 
abdomen, which, after lasting twenty-four hours, at once 
lost its acuity and rapidly subsided, when I had assured 
her with great positiveness that she did not have peri- 
tonitis. Once, after receipt of an agitating letter, she 
became apparently delirious and unable to speak for twelve 
hours. This was immediately followed by an intense dys- 
phagia, overcome at last by a combination of moral force 
and local faradization. In the following summer, 1889, the 
patient's health was considerably improved. She engaged 
in some occupation involving considerable fatigue — I think 
teaching in a public night-school — and at once began to 
lose ground again. Early in July, during the second day 
of a menstrual period, she accompanied a friend on an 
excursion to Bedloe's Island, and climbed the stairs within 
the statue. The menstrual flow was immediately arrested, 



HYSTERICAL FEVER. 



375 



and severe pain appeared in the left ovarian region. On 
the 22d of July she was admitted to the New York Infirm- 
ary, and on the 23d had a temperature of 102 , and the next 
day of 103°. The fever persisted at about this range till the 
13th of August, when, after two days of normal tempera- 
ture, it rose once more to I03 : , and thence fell to a range 
between 98 and 101.5°, which it maintained till the middle 
of September. During this time I did not see the patient, 



July 221 231 24] 25 1 26 ( 27|28i 29 '30 1 31 | I | 2 I 3 1 4 | 5 I 6 [ 7 I 8 ] 9 ] 10 | II ] 12. ( 13 

"TT m ; e 'mIe m e met [he he r Ei^ E ri E n.Eln'E n ehe'm eme'ce me m rMlEVr 




as I was absent from the city. The physicians in charge 
had only a very slight acquaintance with the previous 
history of the patient, and she herself gave an imperfect 
and rather misleading account of her series of illness. On 
account of the fever, the abdominal pain was explained by 
some focus of parametritis, but it was noted that the pelvic 
examination — made, it is true, with reserve on account of 
the acuity of the accidents — always failed to detect any 
evidence of inflammatory exudation. 

On my return in the middle of September, the patient 
was in about the same condition as at the beginning of the 
attack, and quite the same as in the middle of August, after 
the fever had fallen to a low grade, Upon hearing the 
history and combining it with that of the many and varied 
attacks which I had previously and minutely observed, I 
ventured to express the positive opinion that on this occa- 
sion also no really inflammatory process had ever existed. 



376 MARY PUTNAM JAAOBI. 

but that the accidents were nervous, and initiated by an 
ovarian irritation, the latter due to the arrest of menstrua- 
tion by an unwonted physical exertion which involved the 
nerves of the lower extremities, /'.£-,, of the lumbar plexus, 
which also innervates, to a great extent, the ovary. It seemed 
probable that the menstrual arrest had left a congestion of 
the ovarian cortex, or even that minute hemorrhages had 
occurred there. The patient was put under ether, and a 
most thorough pelvic examination made, both by myself 
and by Dr. Cushier, with a completely negative result. Dr. 
Cushier admitted that the entire absence of any trace of 
exudation at this time, though some irregular low fever 
persisted and the abdominal pain was as severe as ever, 
rendered it altogether improbable that a parametritis had 
ever occurred. 

With the concurrence of Drs. Cushier and Kilham, there- 
fore, I positively assured the patient that she had no pelvic 
inflammation, that the attack was of the same nature as the 
others in which I had previously attended her ; that she 
could safely get up from bed as soon as she pleased ; and 
that a few applications of galvanism to the abdomen over 
the seat of the pain would rapidly dissipate it. 

The applications were, in fact, made with the positive 
electrode over the ovarian region of the abdomen, the neg- 
ative over the lumbar spine. Each application entirely 
removed the pain for many hours. But it seems probable 
that the moral effect of the diagnosis was quite as important, 
so rapidly did the patient change her attitude and so soon 
was she able to get out of the bed on which she had been 
lying for two months In a week she was walking about; 
in ten days was entirely free from pain. The temperature 
remained normal from the day of the examination under 
ether. 

Before the modern researches upon fever as the result 
of poisonous material circulating in the blood, the concep- 
tion of a purely "nervous fever" was an entirely familiar 
one. Indeed the abdominal typhus, which is now recog- 
nized as a typical example of infectious disease, was con- 
sidered, not so very long ago, as a "nervous fever," and 



HYSTERICAL FEVER. 377 

liable to be produced by causes which greatly fatigued or 
exhausted the nervous system. 

The well-known urethral fever was an admitted case of 
a purely nervous fever of reflex origin. "Febrile move- 
ments" of all kinds were easily explained by varying func- 
tional irritations of the nervous system, among which were 
not reckoned irritaments conveyed to nerve centres in the 
blood nourishing them. Indeed, even the fever of inflam- 
mations was referred to the peripheric irritation of the 
nerves of the inflamed tissues ; and not until much 
later was it suggested that some materies morbi was car- 
ried from the focus of inflammation to the central nervous 
system. 

To-day, however, the point of view has so radically 
changed, that it is easy to forget that all the modern 
explanations of fever simply increase the list of irritaments 
to which the pyrogenic apparatus of the nervous system is 
susceptible. Although there be as there undoubtedly is, 
increased production of heat during fever, it is established 
that this would not cause a rise of body temperature unless 
the elimination of heat were simultaneously deranged abso- 
lutely or relatively. But this derangement in the elimina- 
tion of heat depends upon disorder of the heat-regulating 
apparatus of medullary and cerebral centres, which thus 
react to the influence of the chemical poisons generated by 
inflammation or infection. There is, therefore, no essential 
contradiction between the new and old views about fever. 
An exclusively nervous cause is always plausible, because 
the proximate cause of increased body heat is always to be 
sought in the nervous system. 

Before the thermometer was supposed to enable us to 
differentiate with precision between inflammatory and non- 
inflammatory pain, the liability of hysteria to simulate 
inflammations, and especially those of the abdominal cav- 
ity, was one of the well-worn themes of text-books. 
"Hysterical Peritonitis" is a classical chapter in every dis- 
sertation on hysteria, and in every guide to differential 
diagnosis in abdominal disease. But I think that to-day — 
and the case I have related shows it — we are liable some- 



378 MARY PUTNAM JACOB I. 

times to be misled by an habitual, though legitimate, reli- 
ance on the thermometer as a means of differentiation. It 
is easy to decide in the absence of fever that pelvic pain 
must depend upon some other cause than inflammation ; 
and in the great majority of cases this conclusion is con- 
firmed by the absence of all physical signs of exudation. 
Yet Dr. Thomas and some other gynecologists declare 
that an extensive pelvic exudation may be formed, and 
with considerable rapidity, without the slightest rise of 
temperature ever being produced. However this may be — 
and I confess never to have myself seen the statement 
proved — the two attacks of pseudo-parametritis attended 
by fever, which were sustained by the highly hysterical 
patient under discussion this evening, serve to illustrate 
the converse proposition, namely, that a rise of temperature 
may occur under circumstances strongly suggestive of pel- 
vic inflammation and yet all positive proof of true inflam- 
mation be entirely lacking. 

Hysterical fever has lately received much attention from 
both English and French physicians. In 1883 Pinard wrote 
a thesis on the pseudo-fever of hysterics, in which he claimed 
to show that hysterical fever did not really exist: — that is, 
in the cases described : either no thermometrical observa- 
tion had been taken, or the thermometer registered a tem- 
perature not above 38 C, while often the temperature 
remained normal. The pseudo-fever consisted, therefore, 
in an assemblage of symptoms which simulated fever, but 
were not truly febrile. Among these was conspicuous the 
acceleration of the pulse, phenomenon essentially analogous 
to the tachycardia of exophthalmic goitre. The patients 
often had subjective sensations of heat, also severe headache 
and coated tongue. This condition was not unfrequently 
regularly paroxysmal, so as to simulate attacks of malarial 
fever, but was entirely uncontrolled by quinine. 

In a more recent thesis, passed by Henri Fabre in 1888, 
the existence of a true fever, and even hyperpyrexia of 
really hysterical origin, is, however, formally reasserted. 
Cases are related where such fever was accompanied by 
functional disturbance of various organs, so as to simulate 



HYSTERICAL FEVER. 379 

respectively meningitis, peritonitis, or pneumonia. Inter- 
mittent fever and typhoid fever are also said to be simulated. 
The same assertion is made by an American physician, 
Bressler, in a communication to the "Medical Record," for 
1888. This writer relates no cases in detail, and I do 
not think that his diagnosis is absolutely proved by his 
descriptions. 

" By hysterical fever," says Dr. Bressler, " I mean a 
perverted condition of the nervous system, occurring in a 
neurotic individual, attended by an elevated temperature, 
which may last from a few hours to several days, and is 
associated throughout its duration with symptoms of an 
hysterical character." " This fever," continues the writer, 
" generally begins with symptoms simulating a mild inter- 
mittent — chilliness, loss of appetite, constipation, or occa- 
sional diarrhoea ; tongue coated, headache, general malaise, 
rise of temperature, face flushed generally, or in a circum- 
scribed spot on the cheeks, eyes clear and brilliant, mind 
bright, comprehension quickened. There is general mus- 
cular and cutaneous hyperesthesia. The special senses are 
more acute ; there is no true delirium. The stomach is 
excessively irritable, and vomiting very persistent. The 
abdomen is extremely sensitive to pressure, and peritonitis 
may be simulated, but may be excluded by the fluctuating 
character of the pains, the absence of tympanitis, and the 
development of ovarian pain under pressure. The tempera- 
ture varies from 101 to 105 F., and the maximum is reached 
early in the attack." 

In the " Transactions of the London Clinical Society," 
Dr Hale White relates the following case: A girl of eighteen 
was admitted to the ward, on the 10th of August, for a febrile 
attack, which lasted four days, and then subsided. On 
September 8th she was suddenly taken ill with a severe 
pam in the left side, and was readmitted to the hospital the 
next day. The patient could hardly walk, and was some- 
what incoherent in speech. Within the course of twelve 
hours the pain was located in four different places— the left 
iliac region, the epigastrium, the lumbar region, the splenic 
region. The attention of the patient was easily diverted by 



380 MARY PUTNAM JAC0B1. 

conversation, and she then permitted considerable pressure 
over the seat of the pain. The temperature was at first \oy ; 
on September 10th, after a chill, rose to 105-, to fall in the 
evening to 99"". On the 11th, at 6 A. M., the temperature 
was 98. 6 3 , at 6 P. M. 104" ; September 12th the temperature 
did not rise till evening, when it was 102 : at 6 and 98.8"" 
at 10. 

In the analysis of the case Dr. White excluded all othe r 
causes of either the pain or the fever except hysteria. But 
it is noticeable that the patient vomited on two successive 
days, and during the previous brief illness in August there 
had also been symptoms of a gastro-duodenal catarrh. It 
seems to me that such an organic condition really existed, 
and was the immediate cause of the neurotic condition upon 
which the wandering pains, and markedly irregular fever, 
directly depended. 

Dr. White remarks that, although several cases of hys- 
terical pyrexia have lately been recorded, much skepticism 
has been expressed in regard to it. Among these recorded 
cases is one by Clemrow, in the " Medical Press and Cir- 
cular," of 1887. A laundrymaid, of twenty-three, was 
admitted to the Edinburgh Royal Infirmary, October 22d, 
with dizziness, pain in the left side, and a purpuric rash over 
the lower extremities. On the 29th of November the patient 
had a severe fright, and her temperature rose to 107. 8 C 
After this the records of temperature are so extraordinary 
as to suggest fraud, were it not that there was no way in 
which a fraud could have been effective. At midnight of 
the same day three successive records, taken at short 
intervals, read iii c , io8 : , 98^. On November 30th the 
temperature in the right axilla was I08°; the left, at the 
same time, 994". At midnight the temperature was 98 ; on 
the right side and io8 c on the left. Similar local maxima, 
varying from hour to hour, were observed on the 1st, 2d, 
and 3d of December ; after which the records are not given. 
On November 30th the patient had several spasms simulat- 
ing tetanus, probably hysterical opisthotonos. On Decem- 
ber 1st, together with headache and nausea, there was a 
peculiar rhythmical movement of the eyelids, alternate 



HYSTERICAL FEVER. 38 I 

elevation and depression. There was left internal strabis- 
mus, and sluggish reaction to the light of the right pupil. 
Throbbing pain at the vertex increased by pressure. On 
December 3d there were frequent spasms, with muffled 
heart-sounds; pulse at the wrist imperceptible. 'On Decem- 
ber 4th the patient became delirious, and continued so until 
the 13th. The plantar and patellar reflexes were both 
absent ; there was cutaneous anaesthesia, incontinence of 
urine and faeces. After the 13th these symptoms disap- 
peared, and the patient began slowly to improve. But she 
was not fully recovered until April. 

Clemrow considered the hyperpyrexias to have been 
local, and not extending throughout the body. 

In the " Lancet,'' for 1879, Donkin related the case of a 
girl of nineteen, who, during convalescence from a mild 
typhoid fever, had, at frequent intervals, temperatures of 
io8 c or iicr. These were of short duration, and unaccom- 
panied by other symptoms than a sensation of heat. 

In another case, observed by the same writer, from the 
20th of May to the 20th of June the temperature every 
morning and evening varied between ioi.8 : and io6.8 c 

Donkin quotes similar cases from Creig Smith, Cliffe, 
and Meade. The last, like Donkin's own case, was also a 
girl convalescent from typhoid, whose temperature for a 
month kept incessantly varying from I03 ; to 109/, some- 
times in fifteen minutes would run up to nr. In these 
English cases the temperature was always taken in the 
axilla. 

In the " Gazette Hebdomadaire," for 1S86, Debove de- 
scribes a patient who. every day for a month, and without 
other symptom, presented morning and evening a tempera- 
ture of 39.5 c C. This was in November. In December the 
temperature rose to 40 : , on the 17th of January was 41.4' 
and on the 24th reached a final maximum of 41.4 : . After 
this it slowly fell, and became normal on the 30th. During 
this period of three months the morning and evening tem- 
peratures were almost always alike : occasionally one or 
the other was higher by one-tenth or two-tenths of a degree. 
This prolonged hyperpyrexia resulted in no emaciation or 
loss of strength. 



382 MARY PUTNAM J A COB I. 

In 1886 Barie described a case (also in " Gazette Heb- 
domadaire"), a severely hysterical young woman, servant 
at Bicetre. She was subject to frequent convulsive attacks- 
transient paralyses, profound disorders of sensibility. One 
morning, after a violent convulsion, she became completely 
hemiplegic, on theleft side, except the face, as regarded 
both mobility and sensibility. After this she had thirty 
convulsive attacks in the course of twelve days. Sometimes 
for two or three days together she would remain in a state 
of complete mutism, without eating and also without urinat- 
ing. All remedial measures failed, and the physician con- 
tented himself with simple observation. One morning, 
after a violent convulsive attack, the temperature in the 
axilla was found to be 39° C. From this time, for twenty 
days, there was permanent fever, as measured both in the 
axilla and rectum. Evening temperature was usually higher 
than morning by some tenths of a degree, but on five days 
the morning temperature was the highest. There was no 
functional disturbance, and the tongue remained moist. 
The fever was highest on the days of the attacks, but per- 
sisted'on the other days also. On the twentieth day sudden 
defervescence occurred, the patient remaining otherwise the 
same, neither better nor worse. 

In the " Periscope" of the Journal of Nervous and 
Mental Disease, for February, 1890, is described a case 
of hysterical pseudo-phthisis where, during three days, the 
temperature varied from 103° to IO4 F.; on the fourth day 
it rose to 113°, and the patient became slightly delirious. 
In an hour the temperature fell to 108 ; in the evening was 
106.3°. O n the next day it again rose to 1 13°, but fell in an 
hour to 995". During the next few days the temperature 
varied from 101.3 to 103.1°, and then became normal. The 
symptoms had begun with an attack of haemoptysis, which 
was followed by severe dyspnoea, cyanosis, and apparently 
threatened asphyxia several times during the night. During 
the next two months the same group of symptoms was 
repeated several times with complete absence of physical 
signs of phthisis. There was retention of urine. 

The most interesting cases quoted in the thesis of Henri 



HYSTERICAL FEVER. 383 

Fabre are two, of simulated meningitis, one of apparently 
severe pulmonary disease. The first of these, a young 
woman of twenty-four, who had previously suffered from 
chorea and nervous aphonia, was admitted to the hospital 
with a temperature of 39.5 s C. Her face was swollen and con- 
congested, eyes closed on account of an intense photophobia. 
The head was retracted completely, cephalalgia violent, 
insomnia and cries, abdomen retracted, constipation abso- 
lute, meningitic streak easily developed, severe generalized 
hyperesthesia, knee-jerk little modified, no morbid condi- 
tion discoverable in lungs, heart, or kidneys. During ten 
days the patient remained in about the same condition : 
prostrated, eyebrows contracted, pupils contracted but 
equal, five or six times bilious vomiting without effort (hav- 
ing all the appearance of cerebral vomiting). A diagnosis 
was made of tubercular meningitis, and (but with little hope 
of doing any good) leeches were applied behind the ears 
and calomel administered. On the tenth day the patient 
was found sleeping naturally, and, on being aroused, ceased 
to complain of the pain in her head. The temperature had 
fallen to 38 s C. In a few days more the patient was fully 
convalescent, but on first getting up was affected by a 
transient paraplegia. 

The history of the second case closely resembled the 
first. 

I have myself seen a similar case in the service of Cornil 
at La Charite, and, curiously enough, the same patient 
returned, a year later, with the same group of symptoms, 
and, her personality being recognized, the diagnosis was 
the second time at once correctly made. 

The case of febrile hysteric dyspnoea related by Fabre 
is as follows : The patient was a woman of twenty-six ; 
admitted to the hospital with an evening temperature of 
39 c C. and a dyspnoea of five or six days' duration. There 
were thirty-five to fort)' respirations a minute, but unaccom- 
panied by trace of cyanosis. The most careful auscultation 
failed to discover any lesion of either lungs or heart, and 
the absence of albuminuria was held to exclude a uraemic 
origin to the dyspnoea. The fever continued for twenty 



384 MARY PUTNAM JACOB I. 

days, being extremely irregular, with occasional intermis- 
sions of normal temperature, followed by a rise to 39° or 40 
or over. On the twentieth day occurred an abrupt defer- 
vescence, and at the same time the dyspncea ceased. 

The recognition of hysterical fever as a distinct clinical 
affection has been much facilitated by recent researches on 
the relations of the cerebro-spinal nerve-centres to the 
temperatures (general or local) of the body. As every one 
knows, these researches were initiated by the famous obser- 
vation of Sir Benjamin Brodie, on a rise of temperature in 
a few hours to ni c F., in a patient who had sustained a 
fracture of the spine, with traumatic section of the cord. 
This observation was published in the " Medico-Chirurgical 
Transactions" in 1837. 

The researches of Tscheschin, in 1866, are equally famous 
and well known. In some respects they seem in contra- 
diction with Brodie's clinical observation : for when, in 
animals, this experimenter cut the spinal cord below the 
medulla, the temperature of the body fell ; but if the section 
were made between the medulla and the pons, the tempera- 
ture rose excessively. 

The more exact experiments of Horatio Wood, in his 
beautiful researches on fever, published in 1880, demon- 
strated that when the spinal cord was cut anywhere 
between the level of the third and second cervical vertebra 
there was at first an enormous increase of heat-dissipation, 
correlative with the general vaso-motor paralysis ; that in 
forty-eight hours this was followed by a diminution in the 
dissipation of heat, but also a diminution in heat-produc- 
tion, so that, as had been before observed, the net result 
was a fall of body temperature. Wood also observed 
the rise of temperature consecutive to section of the cord 
between the medulla and pons. He accepts the inference 
drawn from the facts by Tscheschin, that there exists in the 
medulla some nerve centre or centres whose influence tends 
to stimulate the production of heat in the thermo-genetic 
tissues, namely, the muscles ; that this influence is habitu- 
ally restrained by that of moderating centres in the pons 
or above it, and that the rise of temperature observed in 



HYSTERICAL FEVER. 385 

the last experiment is due to the withdrawal of this moder- 
ating influence from the real heat centres. More recent 
experiments have extended the field of experiment and 
inquiry. Eulenburg and Landois showed that excitation 
of one cerebral hemisphere is followed by a local rise of 
temperature in the limbs of the opposite side. These 
experimenters made no observations on the general tem- 
perature. In 1884, Charles Richet (Compt. Rend. Societe 
Biol., 22 Mars, 1884) pricked one cerebral hemisphere of a 
rabbit with a steel pen which perforated the cranium, and 
and found in the course of two hours that the rectal- tem- 
perature rose from 39. 5 = C v to 40.4°. The next day, when 
the temperature had fallen to 39. 2 Q , a nerve pricking caused 
a rise to 42. 8°. The animal died in the night, presumably 
of the hyperpyrexia, as no brain lesions were discovered to 
explain the death. It was found that the pin had pene- 
trated to a spot situated three or four millimetres in front 
of the corpus striatum. 

A little later, Schreiber^ found that a rise of temperature 
occurred after lesion of any part of the pons, of the cerebral 
peduncles, cerebrum or cerebellum, provided the animal 
operated on were protected from the radiation of heat by 
wrapping in cotton wool. In 1885, Aronsohn and Sachs in 
Germany, and Dr. Isaac Ott in America, began almost 
simultaneously, but quite independently of each other, to 
search for heat-regulating centres in the brain. The Ger- 
man observers 3 trepanned rabbits at the juncture of the 
sagittal and coronal sutures, and entered the brain with a 
needle, three millimetres broad, at a point about one milli- 
metre outside the longitudinal sinus. A carbolized dress- 
ing was immediately applied, and the well-being of the 
animals seemed to remain undisturbed. 

When the operation was performed on the cerebrum 
anterior to the Rolandic convolutions, no effect on the 
temperature was observed. But the punctures which passed 
to the base of the brain, from the point of junction of the 
coronal and sagittal sutures, were always followed by an 

2 Pfluger's Archiv., viii., S. 576. 

3 Pfluger's Archiv., 1885. 



J 



86 .hAKY PUTNAM JACOB/. 



enormous rise of temperature. If the puncture only pene- 
trated the cortex cerebri, no effect on temperature was 
produced. Electrical irritation of the susceptible region, 
i. e., the tissue just in front or on the outer side of the 
corpus striatum, also caused a rise of temperature. An 
increased excretion of nitrogen was observed during this 
artificial fever, so an increased heat-production was infer- 
red, but no calometrical observations were made. 

These difficult observations were, however, made by 
Ott, 4 and add greatly to the value of his experiments on 
the brain. 

Ott established four localities at the base of the brain 
whose puncture, and consequent irritation, was followed by 
a rise of body temperature. These were, at a point just within 
the anterior part of the corpus striatum ; a second point 
between the corpus striatum and the thalamus ; a third at 
the anterior part of the thalamus ; and a fourth at the point 
of decussation of motor fibres at the nib of the calamus in 
the medulla. In the fever consecutive to irritation of these 
centres, there is at first an increase of both heat-production 
and heat-dissipation, but both soon fall below normal, 
though fever continues. In addition to these centres, how- 
ever, Ott discovered two others on the cortex; one at the 
point of juncture of the supra sylvian and post sylvian 
fissure; the other in the neighborhood of the cruciate sul- 
cus, i. e., over the Rolandic convolutions. 

When either of these cortical centres were irritated, 
temperature was depressed. If, on the other hand, they 
were removed by slicing and subsequent washing with car- 
bolized water, the temperature rose. 

From the total result of his experiments, Ott infers that 
the basal centres, like those of the spinal cord, habitually 
stimulate the production of heat; are thermogenetic cen- 
tres. But those of the cortex, the sylvian and cruciate, 
habitually restrain the activity of these lower centres, and 
may therefore be called thermotaxic. 

Under certain circumstances the striate and extra stri- 
ate centres may also be thermotaxic, and moderate the 
* Journal Mental Disease, 1888. 



HYSTERICAL FEVER. 



\*7 



spinal centres below them. They have, therefore, a mixed 
character or function. 

Girard 5 confirmed the results of Ott's experiments on the 
corpus striatum, and also observed a rise of temperature to 
follow punctures at various localities in the posterior part 
of the brain, but none when these were made anteriorly. 
The fever was attended by increased elimination of nitro- 
gen in the urine, and was controlled by antipyrine. Rise 
of temperature was also induced by faradising the striated 
bodies for half an hour with needles insulated to their tips. 

Horatio Wood, also, in thirteen out of fourteen experi- 
ments, found that localized destructions of tissue just 
behind the crucial sulcus, thus compromising Hitzig's 
region, were followed by a rise of temperature and decided 
increased of heat-production. 

A curious confirmation of the foregoing observations is 
offered by Zawadowski,* who found that antipyrine ceases 
to reduce temperature if administered after section of the 
spinal cord at the atlas, an operation which removes the 
inhibitory influence of the brain from the thermogenetic 
centres of the cord. 

The interest of the foregoing observations is very great 
in their bearing on the general theory of fever. In accord- 
ance with them, all fever can finally be ascribed to derange- 
ment of the central nervous apparatus, which controls the 
generation of heat in the muscles, the latter being the 
ultimate thermogenetic apparatus. Hence, the striking 
fact, that the cerebral centres so far established as regu- 
lating the production of heat, are chiefly situated on the 
motor tracts, namely the Rolandic convolutions, the striate 
centres, and the medulla. 

In zymotic fever the thermogenetic centres would be 
irritated by the poison circulating in the blood ; in trau- 
matic, perhaps also in inflammatory fever the same result 
is produced by irritation of peripheric nerves ; in hysteria 
there would be paralysis of the cortical thermotaxic inhibi- 
tory centres rather than excitation of the basal thermo- 

> Archives to Physiol., 1886 and 1888. 
6 Centralblatt f. medicim-wissen, 1888. 



388 MARY JACOBY PUTNAM. 

genetic centres. 7 Reflex fevers, like urethral and worm 
fever, might be supposed to imply, on the other hand direct 
irritation of the thermogenetic centres. 

This paralysis would then enter into the entire 
series of hysterical phenomena, which depend upon loss of 
cortical control over lower centres. It becomes analogous 
to the loss of cortical control over subcortical vaso-motor 
centres, upon which Meynert has so strongly insisted, and 
nevertheless it is not to be resolved into a vaso-motor 
phenomenon. For it has been shown, especially in some 
experiments of Wood's, that the vaso-motor medullary 
centres are not affected in these artificial fevers, and 
respond as usual to an irritation of the sciatic nerve. 

A danger attends the recognition of any group of clin- 
ical symptoms as hysterical. It is the danger of ascribing 
to hysteria, symptoms which are really caused by organic 
disease. This is even more serious than the opposite error 
of interpreting as the result of organic disease, symptoms 
really due to hysteria. The diagnosis is, therefore, always 
important, and often delicate and difficult. It would be 
impracticable in this place to analyze the elements of diag- 
nosis in regard to each case which might be simulated. 
But this may always be remembered : Exclusion of the 
grave organic lesion which may be simulated, does not 
necessarily exclude the origin of the disorder in some lesser 
lesion, which may even entirely disappear, while the storm 
which has been aroused continues. The type of such a 
sequence is offered by the prolonged hysterical neuralgias 
which may originate in a slight sprain (traumatic hysteria). 

In the case which forms the basis of this paper, I think 
it is not at all improbable that the last series of accidents 
originated in a slight hemorrhage into the cortex of the 
ovary, occurring at the time of the arrested menstruation. 
A permanent ovarian irritation or irritability existed, man- 
ifested by the persistent recurrence of menorrhagias, in the 
absence of all uterine disease. It seems as if this would be 
sufficient to explain the entire series of phenomena, itself 
being an expression of a grave hysterical diathesis. 

■ W. Hall White, loc. cit. 



A CASE OF CHOREA ATTENDED WITH MUL- 
TIPLE NEURITIS. 1 

By FRANK R. FRY, A.M., M.D., of St. Louis. 

BARBARA MUELLER first presented herself at the 
clinic for diseases of the nervous system, at the 
St. Louis Medical College, January 23, 1886. She 
was then eleven years of age. Nothing of importance in 
family history was obtained, except that her father, who 
always accompanied her to the dispensary, occasionally had 
attacks of sub-acute rheumatism ; and that her younger 
brother had been treated by us for chorea, as I shall here- 
after explain. 

She had a general chorea, attended by no unusual features 
that were then discovered. The movements were more 
pronounced on the right side of the body, including the face. 
A slight paresis was apparent in the extremities of this side 
when the choreic movements were disappearing. This was 
transient. When she first came she was anaemic, restless, 
sleepless, and very irritable. These symptoms soon began 
to disappear. She made a rapid recovery, and was dis- 
charged within a few weeks apparently well, having gained 
considerably in weight and greatly improved in general 
appearance. The treatment consisted of arsenic and iron, 
and, at first, bromides at night. 

March 24, 1887, she returned to the clinic. Her father 
stated that she had appeared to be very well until a few days 
prior to this date, when she complained of starting from her 
sleep at night. Her appetite was failing ; she was becom- 
ing very restless and peevish, and complained of the lumps 
on her legs. There were decided but feeble general choreic 
movements of the whole bodv. On the lower extremities 



Read before the Medical Association of the State of Missouri, May 7. 1890 



390 FRANK R. FRY. 

there was a typical erythema nodosum, of which she com- 
plained considerably. The heart's action was feeble and 
rapid. There was no murmur. She did not seem to be so 
anaemic as when she came the year before, but she showed 
evidence of a general debility or lassitude which contrasted 
strongly with her condition when she had discontinued 
treatment the previous spring. 

April 9th, after a careful examination, I found that none 
of the tendon- or skin-reflexes in the extremities could be 
produced. I did not try the nose or pharynx. I noticed 
for the first time on this date an inequality of the pupils, the 
left remaining decidedly larger. Dr. William Hunicke made 
an examination, and was unable to assign a satisfactory 
cause for the inequality, but thought it possibly due to some 
central disturbance. The choreic movements became a 
little worse, but were not severe enough to cause much 
inconvenience. All of the symptoms, including the chorea, 
soon began rapidly to disappear, and she discontinued her 
attendance at the dispensary in the latter part of May (1887), 
apparently well. 

January 3, 1888, she returned again to the clinic. She 
had a return of the chorea, which was general but not 
severe. Her general condition seemed better than when 
she applied for treatment on the former occasions. Her 
visits were not frequent, and nothing remarkable was noted 
until 

February 4th, when she came with a marked paresis of 
the lower extremities, which, so far as could be learned 
from the father, had developed within a day or so. The 
dropping of the toes in walking, or the gait characteristic 
of paralysis of the anterior tibial nerves, was remarked. 
The knee-jerk was gone. She complained of tingling in the 
feet. Arsenic was discontinued. 

February 10th she was unable to walk, and was carried 
to the clinic. She complained of painful tingling in the feet 
and legs and to some extent in the hands. Muscular power 
in the hands and forearms was very feeble. From this date 
her visits to the clinic were infrequent. 

April 1 2th (two months after the declaration of the 






CHOREA, WITH MULTIPLE NEURITIS. 391 

paralysis) the first careful electrical examination was made. 
It showed a reaction of degeneration in the muscles of the 
hands, feet, forearms, legs, arms, and thighs. The muscles 
were considerably atrophied and already somewhat con- 
tractured, the toes being flexed and the ankles extended, 
the hands and wrists presenting the first stage of the well- 
described bird-claw deformity. Tactile and temperature 
sense were almost nil over the areas of motor paralysis. 
The deep and superficial reflexes were gone. The muscles 
of the face, neck, and trunk were not involved ; neither was 
sensation disturbed over these areas. 

May 1st there was the first evidence of improvement, she 
being able to slightly move the arms. From this time im- 
provement was continuous, but very gradual. 

May, 1889 (fifteen months after commencement of paral- 
ysis), she was walking very well, the toes, however, drop- 
ping as she raised the feet in stepping, giving an appreciable 
halt to the gait, although she could walk fast. The deform- 
ity was fast disappearing from the hands. The muscular 
power in all the extremities was good. 

I last saw her in November (1889). There was then a 
barely appreciable dropping of the toes, suggesting more of 
a stiff gait from tight shoes than a paralysis or paresis of the 
anterior tibial nerves. The usefulness and shape of the 
hands were completely restored. So far as I could deter- 
mine, sensation was about normal. The knee-jerk was still 
absent. Her general condition was very good. 

The immediate cause of this paralysis was undoubtedly 
a multiple neuritis. That it was not a cerebral paralysis is 
apparent ; for, besides its character — i. e., an atrophic paral- 
ysis with the reflexes gone — it had not the distribution of 
a cerebral paralysis. That it was due to disease of the 
peripheral portions of the spinal nerves, and not of the cord, 
an examination of the facts makes clear : It was symmetri- 
cal, so much so indeed that the deformity of the hands was 
almost identical on the two sides, and also the amount of 
flexion of the toes. It was not only symmetrical, but the 
paralysis was most profound in the distal portions of the 
several extremities, lessening toward the trunk. The sen- 



392 



FRANK R. FR Y. 



sory disturbance was extensive — in fact, coextensive with 
the motor paralysis, and persistent. Although the paralysis 
was profound and extensive and accompanied with atrophy, 
the recovery was complete. 

The question now comes, what was the cause of the 
neuritis? It could not have been of alcoholic origin, as 
there is positive evidence that none was taken. There had 
been no exposure to cold or wet, to account for it. A 
neuritis of this description is said to sometimes accompany 
or follow rheumatism ; but our patient had never had rheu- 
matism nor any articular trouble. It was suggested at the 
time that it was possibly due to arsenic, which she had been 
taking for a month, prior to which time she had had none 
for eight months. She had taken larger quantities for a 
longer time on former occasions, had borne it well, and 
improved during its administration. The drug was entirely 
and permanently discontinued on the appearance of the 
paralysis ; yet the latter ran a tedious course, as described 
above. That the neuritis simply followed an exhausted or 
depreciated condition of the system, caused by chorea, as it 
sometimes does typhoid, phthisis, etc., may not, I think, be 
too readily conceded. In the first place, the association of 
multiple neuritis with phthisis, typhoid, diphtheria, and 
similarly debilitating diseases is by no means clear. In the 
second place, there were no unusual evidences of exhaus- 
tion or vitiated condition of the system on this occasion ; in 
fact, when she was seized with the paralysis, her general 
condition seemed better, as stated in the history, than on 
the occasions of her former attacks of chorea. 

Before attempting to look further for a possible etiologi- 
cal factor, I shall briefly relate, as a matter of incidental 
interest, our experience with this girl's brother. Fourteen 
months prior to her first visit to us he was brought to the 
dispensary with his first attack of chorea. He was then 
seven years old. He has returned once or twice every year 
since to be treated for the same trouble. On most of these 
occasions there has been an unusually rapid and marked 
change in his general condition following the administration 
of arsenic ; beyond this nothing especially remarkable until 



CHOREA, WITH MULTIPLE NEURITIS. 393 

last fall. At this time there were, for the first, pains in the 
joints, and finally sub-acute arthritis with swelling and 
slight fever. Later still a soft murmur appeared in the 
heart, and persisted for about three weeks. The pulse was 
rapid, irregular, and weak. These symptoms all disappeared, 
and when he left us he was as well as I have ever seen 
him. 

Cases of chorea occasionally occur which suggest, in 
some respects at least, the possibility of an infectious origin. 
Some observers have been so impressed with the fact, that 
they have undertaken laborious investigations looking 
toward the discovery of unknown factors, possibly infectious, 
in the etiology of this disease. In a paper : which I read 
before the Mississippi Valley Medical Society four years 
ago, I reviewed at some length a paper on the " Prechoreic 
Stage of Chorea," read by Dr. C. R. Stratton at the annual 
meeting of the British Medical Association in 1885. He 
reminds clinicians of the fact that a considerable proportion 
of the young subjects in whom chorea appears are found to 
have been in a prodromal stage, so to speak, characterized 
by anaemia, general lowered vitality (accompanied often 
with sores on the margins of the lips and nose), blunted 
intellect, great physical and mental irritability, sometimes 
by slight febrile action, vague pains and swellings of the 
joints, heart-murmurs, etc.; and that, in this condition, they 
are often treated for malaria, rheumatism, general debility, 
etc., until the chorea appears. With these clinical facts in 
mind, he suggests that chorea may be not a constant but an 
occasional result or symptom of some malady or maladies, 
possibly infectious, whose characters are not yet known to 
us. He made examinations of the micro-organisms found 
in the sores on the lips and nose, and, in post-mortem cases, 
of the vegetations found on the valves of the heart, and of 
certain minute infarctions found in the nerve-centres. In 
these vegetations he found the same organisms that he 
found in the sores on the face ; and he believed the infarc- 
tions to be formed from small particles carried from the 

2 St. Louis Courier of Medicine, August, 1886. 



;94 



FRANK R. FRY. 



valve-lesions to the distant capillaries, forming in the 
brain-tissue, and probably elsewhere, a characteristic patho- 
logical condition. Although the microscopical findings 
proved nothing definitely, Dr. Stratton was of the opinion 
that they lent color to his suggestion. In other words, the 
presence of the same micrococcus, which he then believed 
could be proved to possess distinctive characters of staining, 
etc., in these several regions of the body, would seem to 
supplement very well the clinical features sustaining his 
theory of an infectious origin. 

This girl and her brother repeatedly appeared at the 
clinic, as the records show, in this same anaemic condition, 
with restlessness, sleeplessness, and mental excitability, 
with disturbed heart-action, with an unusual eruption in 
one instance in the girl's case and an arthritis and heart- 
murmur in the boy's case. In both these cases sores on the 
margins of the lips and nose were observed and noted, but 
were not invariably present during the choreic attacks. 
The great and seemingly unaccountable change in the con- 
dition of these two patients after a few days or weeks of 
treatment was quite remarkable ; in the boy's case especially 
on two occasions amounting almost to a transformation, and 
a rapid one at that. I do not refer to the disappearance of 
the chorea merely, but to the improvement in general con- 
dition. Like other observers, I have seen, during a clinical 
experience often years in the city, very rapid improvement 
in choreic cases. But I have never seen it so prompt and 
striking and equally unaccountable as in one at least of 
these two cases, which have been under my observation, 
one five, the other four years. If I were looking for cases 
to classify in a category of cases of possible infectious origin, 
I should select these. I have seen others which less forcibly 
impressed me in the same way. Was the extensive multiple 
neuritis in our case possibly due to an infectious cause? 



NOTES OX THE ACTIOX OF GELSEMIUM IN 
SOME LOCAL SPASMS AND NEURALGIAS. 

By M. l.MOGENE BASSETTE, M.D. 

Instructor in Electro-Therapeutics and Clinical Assistant in the Department of Diseases of the 

Nervous System in the Pniladelphia Polyclinic ; Clinician to the Gynaecological 

Department of the Woman's Hospital of Philadelphia. 

DURING the last two years I have had opportunities 
at the Polyclinic, and to a less extent at the 
Woman's Hospital and in private practice, of ob- 
serving the effects of gelsemium. From this experience the 
drug seems to be serviceable in the treatment of some local 
spasms, some neuralgias, and a few distressing and unpleas- 
ant head symptoms, such as a feeling of fullness, beating 
and throbbing. That the efficient dose of the remedy, and 
by this I mean of the same preparation, varies through 
wide limits for different individuals is one of the most 
striking facts in reference to it. 

The first and chief case to which I will refer in these 
notes was one of spasmodic torticollis, a patient who came 
to the Polyclinic in November, 1889, having developed 
clonic spasm in the muscles supplied by the spinal acces- 
sory nerve after an accident in which she was thrown out 
of a wagon. She was used by Dr. Mills as a text for a 
lecture at the Philadelphia Hospital, a report of which was 
published in the "University Magazine," February, 1890, 
and the details of the case can be found in this article. The 
spasm was very severe in character, and was brought on 
and increased by walking, excitement, or by pressure in 
the left occipital region. It stubbornly resisted treatment 
by such means as potassium iodide and bromides, mercury, 
salicylates, arsenious acid, assafcetida, sumbul, blistering, 
and the actual cautery. 

The present notes refer almost entirely to the use of 
gelsemium, which was carried to an extreme and with 



396 M. IMOGENE BASSETTE. 

great benefit. She was first placed upon the fluid extract 
of gelsemium in doses of five drops four times daily ; and 
this dose was increased daily by one drop until she took 
twenty-four drops four times daily, up to which time no 
constitutional effects were visible. She was then placed 
upon Parke, Davis & Co.'s normal liquid gelsemium, begin- 
ning with five drops three times daily. The dose of this 
was also increased until she took twenty drops, when she 
began to see double and feel dizzy. The drug was omitted 
for one day, and she was then again put upon twenty drops, 
and this was increased to twenty-five with no effect. (Two 
drops of fluid extract of gelsemium are equal to about one 
minim.) 

At this time, January 18, 1889, she went to the Woman's 
Hospital, under the care of Dr. John B. Roberts, who placed 
her upon Shoemaker's fluid extract of gelsemium, begin- 
ning with five-minim doses. January 19th the dose was 
increased to* ten minims ; this was further increased 
between the 19th and 31st, until she was taking twenty 
minims — she then complaining of dizziness and distrub- 
ance of vision, once seeing double, but these symp- 
toms lasting only a short time. On the 31st she began 
to take seven minims every two hours, day and night, this 
to be increased one drop every other dose after the first 
twelve hours. The next day, February 1st, decided consti- 
tutional effects were obtained, the patient remaining all 
day in bed with double vision and considerable headache. 
These symptoms passed away and gelsemium was con- 
tinued and increased, and by the 4th she had reached 
fifteen minims. The dose was then reduced to thirteen 
minims, and kept at this every two hours both day and 
night. On the 8th the constitutional effects of the drug 
were again marked, and there was now some improvement 
in the spasm and position of the head. She continued until 
the 21st taking thirteen minims every two hours and 
steadily improving. She was now able to walk out without 
suffering, the spasm being better, the head much straighter 
and the muscles softer. 






GELSEMIUM. 397 

On the 2 1st the frequency of giving the gelsemium was 
reduced ; the thirteen minims being now given every two 
hours during the day — the first dose at 7 A. M. and the last at 
7 P. M. — and only twice during the night, at 11 P. M. and 
3 A. M. This treatment was continued forty-seven days 
until she left the hospital. Massage and sitz-baths were 
also used, and March 4th, tincture of chloride of iron, four- 
teen drops an hour after each meal, was ordered. Heat 
and pressure to the affected muscles were also used. April 
9th the patient was discharged, still taking the same dose 
of gelsemium and tincture of chloride of iron. I have heard 
from her within a week, and she still continues better, but 
has not taken any gelsemium for nearly three weeks. 

For three weeks, from January 31st to February 21st, 
this patient took for the greater part of the time twenty- 
six drops or thirteen minims every two hours night and 
day. For another part of this time, alternately, either thir- 
teen minims, or seven and a half minims every two hours, 
or about this amount. For the remaining forty-seven days 
she took about thirteen minims eight times daily. The 
average taken daily, when the maximum amount was 
administered, was about one hundred and fifty-six minims. 
During three weeks, from January 31st to February 21st, 
she probably took between five and six ounces, and during 
the last forty-seven days in all 4,888 minims, equal to eighty- 
one ounces. 

A case of this kind may be worth reporting, both on 
account of the great benefit derived from the use of gelse- 
mium and as a study of the dosage of this drug. It is well 
known that local clonic spasm is usually very obstinate. 
I have seen two severe cases of spasmodic torticollis besides 
this one. In one of these an inch or more of the accessory 
nerve was resected, but the spasm returned with full force ; 
in the other, myotomy was performed, but with no benefit. 
The latter case made remarkable improvement under large 
doses of gelsemium. Numerous cases have been operated 
upon, but without success. The actual cautery, although 
useful, often fails ; it was thoroughly tried in the case 
just reported. Such facts afford an excuse for heroic 
drugging. 



398 M. IMOGENE BASSETTE. 

A woman, B. R., thirty-four years old, brought to the 
Polyclinic by Dr. Bunting, was an illustration of one of the 
forms of painless tic, or spasm of the muscles supplied by 
the seventh nerve. Three years before she noticed a twitch- 
ing under the right eye ; this gradually spread over the 
lower face. Most of the time the lower eyelid was twitching 
spasmodically, and at the same time the mouth was drawn 
upward and outward. When talking or under any excite- 
ment, the spasm increased, so that the eye closed entirely, 
and the face was strongly contracted. The muscles chiefly 
affected were the zygomatics, the levators of the angle of 
the mouth, and the lower half of the orbicularis palpebrarum. 
When the attacks were severe she complained of pain and 
discomfort in the face. She was put upon two minims of the 
fluid extract of gelsemium, four times daily, with directions 
to increase the dose until constitutional symptoms were 
obtained. When eight minims were reached she began to 
complain of dimness of sight, dizziness, and a feeling as if 
she were drunk ; but the spasm was much better than it 
had been for months, and the local sense of pain and dis- 
comfort had disappeared. She was now ordered to begin 
again with five minims four times daily and increase gradu- 
ally. When seven minims were taken she became dizzy, 
her sight was dim, and her limbs felt almost helpless ; but 
the spasm had almost disappeared. The dose was reduced 
to three minims ; and later increased to four minims without 
physiological effects, when the spasm again getting worse, 
the dose was pushed up to seven minims, but the effects 
were so distressing that the gelsemium had to be stopped 
for a week. She is still under treatment. 

In some cases of local spasm patients seem to stand 
large and long-continued doses of gelsemium, much as those 
suffering from severe pain will endure enormous doses of 
opiates or other narcotics. A gelsemium habit is not formed, 
although the drug is taken in immense doses and for a long 
time, one and perhaps the principal reason for this being 
its unpleasant effects. 

In certain neuralgias, particularly those of the upper 
branches of the fifth nerve, both the therapeutic and toxic 



GELSEMIUM. 399 

effects seem to be obtained with much smaller doses. In 
three such cases decided relief of pain was produced quickly 
by the administration of a comparatively small dose of the 
fluid extract of gelsemium. It would be a great gain if we 
could separate those cases of neuralgia in which the drug 
has a favorable action from those in which it proves inert 
or of but little benefit. In one case the patient complained 
of great facial pain, stiffness of the jaw, and pain in opening 
and closing the mouth. She was put upon three minims of 
the fluid extract, the dose to be increased, and by the time 
she had reached six minims the pain had disappeared, and 
the relief was probably permanent, as after several weeks 
she has had no return of the symptoms. In two other cases 
of ciliary and supra-orbital neuralgia the pain was relieved 
by doses of three minims. 

Gelsemium is a drug about which differing reports and 
differences of opinion are common. Cases of poisoning are 
reported which show the small amount of this drug which 
will produce toxic or fatal effects. Boutelle 1 reports a case 
of fatal poisoning in a man, aged twenty-four, who took for 
neuralgia a teaspoonful of Tilden's fluid extract of gelse- 
mium and repeated the dose in fifteen minutes. Friedrich 2 
reports the case of a girl of fourteen, who took a teaspoonful, 
and in less than an hour began to show physiological effects, 
later convulsions, and still later unconsciousness came on ; 
but under active treatment she recovered. Sinkler 3 reports 
the case of a woman who had serious toxic symptoms from 
taking five drops three times daily for ten days, the first 
dose having produced physiological effects. Dr. De Wolfe, 4 
for facial neuralgia, took ten minims of the fluid extract, 
and repeated this in half an hour. In less than fifteen 
minutes he was 'drowsy and could not keep awake ; he was 
taken with shivering, dizziness, and symptoms of collapse ; 
but under the use of stimulants the unpleasant symptoms 
passed away. 

1 Boston Med. and Surg. Journal, 1874. 

2 Philadelphia Medical Times, December 30, 1882. 

3 Philadelphia Medical Times. January 5, 1878. 
« British Med. Journal, vol. i., 181, p. 193. 



400 M. IMOGEXE BASSE TTE. 

In the " Therapeutic Gazette," for June and November, 
1889, an d January, 1890, are some notes and queries, about 
the use of gelsemium, which bring out a few interesting 
points with reference to its dosage. Dr. Hutchings gives 
some personal experience of the drug, and considers a dose 
of fifteen or twenty drops not dangerous. Dr. Lallerstedt 
says that he has been using gelsemium for seventeen years, 
and that he has given as much as one hundred and twenty- 
five minims without the least bad effects ; that he gives it 
to infants and in old age, and that he frequently gives forty 
minims for sick-headache. I agree with the editor of the 
" Therapeutic Gazette," who, in commenting on these state- 
ments, concludes that the fluid extract which the doctor 
used must have been a remarkably inert preparation. The 
editor also records five fatal cases in which the dose which 
led to collapse and death ranged all the way from ten 
minims to a teaspoonful. 

Dr. Weir Mitchell uses gelsemium largely in his prac- 
tice, and was the first to advocate its employment in effi- 
cient and increasing doses for neuralgic and spasmodic 
affections. 



HERNIA CEREBRI. 



Reference is made in the "Medical Record," March 8, 
1890, to Dr. C. E. Olmsted's account of a peculiar congen- 
ital protrusion of brain-substance through the frontal bone 
of a child five years old. The opening in the frontal bone 
was about the size of a silver dollar. Pulsations in the 
tumor could be distinctly seen as well as felt. The child 
had convulsions at irregular intervals, coming on without 
apparent cause, at which times the brain-substance would 
recede through the opening in the skull, and the defect in 
the frontal bone could readily be defined by the finger. 
After the convulsion, the tumor — about the size of a plum 
— would again appear on the forehead. 



REPORT OF AX INTERESTING CASE OF 
FEIGNED INSANITY. 1 

By M. D. FIELD, M.D. 

ON December 17, 1887, my attention was called to 
J. D., who was then a prisoner at the Tombs, in- 
dicted on a charge of grand larceny of the first 
degree. If convicted under this charge, he would have 
been subject to from five to ten years' imprisonment. I 
learned that he had been at the Tombs since November 
1 6th, a period of a little over four weeks. During this time 
the keeper stated he had been in the same state in which I 
found him ; that since admission he had never spoken a 
single word ; and that he had maintained a perfect indiffer- 
ence to everything about him ; that he had never made any 
voluntary movement, except slight opening and closing of 
his lips. If taken hold of, he would follow wherever led ; 
if put in a chair, or any place, there he would remain ; he 
would not take food or water when placed in front of him, 
or if left beside him ; and, given an opportunity to partake 
when nobody was present, it was never found that he had 
taken advantage of such opportunity. If food was placed 
in his mouth, he would swallow, in a mechanical sort of 
way ; the attendants were very confident that it was diffi- 
cult for him to swallow any solid food, and they were in 
the habit of giving him bread soaked in soup. They never 
knew him to voluntarily use the pails, the only means of 
relief in the cells ; occasionally he would pass his urine in 
his clothing, or in the bed ; a few times they have placed 
him on the seat and left him for several hours, when he had 
had slight passages from his bowels. 

JRead at the March meeting of the New York Neurological Society. 



402 M. D. FIELD. 

From the closest questioning, it seems to be a fact 
that his secretions were very much diminished, though, of 
course, he was having a meagre diet, with little fluids. So 
thoroughly convinced were the attendants that he would 
make no effort to help himself in any way, they were afraid 
to let him lie fiat in bed, lest he should smother in the 
pillows and bedding ; they would bolster him up, in a half- 
sitting position, and, though asked to make frequent obser- 
vations, which they claimed to have done, during the 
night, they reported that they never found evidences that 
he had moved from the exact position in which they had 
placed him, and that they always found him in the same 
position, eyes open, and with the same staring expression. 
They also reported that in leading him out and in from his 
cell, the doorway of which was low, that he would strike 
his head against the iron frame, unless they took pains to 
push his head down low enough to go under. In this way 
he received several pretty severe blows, before they guarded 
against injury in this way. In fact, he appeared to all those 
about the prison to be without knowledge of, or interest in, 
things about him, being totally indifferent. 

With this history, I saw and examined him for fhe first 
time on December 17, 1887; and I saw him a number of 
times afterward. He was a tall, spare man; rather pale 
and anaemic. He was led into the examination-room by 
one of the keepers, in front of a chair, when the keeper 
shoved him back, and he sank down without resistance, 
and seemed to simply fall into place. From this position 
he never moved. He had a fixed, staring expression. Only 
occasionally would he wink. He could not be made to 
speak, make any effort, or give any evidence that he com- 
prehended what was said to him or what was going on 
about him. His dress and person bore every evidence of 
perfect neglect. His pulse was rather small and quick ; 
his breathing was shallow ; his temperature was apparently 
slightly subnormal (not taken by thermometer) ; all re- 
flexes, both deep and superficial, appeared normal. His 
limbs, if raised out of position and then released, sunk back 
into position as if from gravitation, but not with the dead 



FEIGNED INSANITY. 403 

fall of a paralyzed limb ; there was nothing of a cataleptic 
nature about the case that I could observe. 

I might remark here that two physicians who had seen 
the case had reported to the District Attorney that he was 
in a cataleptic, or cataleptiform, condition, and not in a 
condition to be tried. If I stood directly in front of the 
man and were to throw water in his face or prick his skin, 
he would give no manifestation of feeling. If I stood behind 
him, where he could not see me, and snapped drops of cold 
water from my fingers, so as to strike the side of his face, 
involuntary movement followed. I made firm and pro- 
longed pressure upon the supraorbital nerve, the only 
response being that his face became much suffused and a 
few tears came from his eyes. But there was no expression 
of pain or anger in his face, though the pain inflicted must 
have been severe, and certainly was as great as I felt justi- 
fied in producing. 

I had repeated interviews with this man, and tried 
various inducements to get him to speak, but without avail. 
One day I had the photographs, which I will exhibit, taken. 
The light was poor, and the exposure made in both cases 
was over a minute and a half. I may remark that the 
photographer was astonished at the perfect quiet of the 
patient during that time, there being not the slightest evi- 
dent movement. The distinctness with which the eyelashes 
are shown will indicate this. I do not believe that the man 
was any stiller while his photograph was being taken than 
during the whole of all, and every, interview that I had 
with him. 

During his stay at the Tombs he must have lost some 
thirty or forty pounds in weight, and, in fact, he became 
very emaciated. I began to think he would starve himself 
to death. On inquiring into the history of this man, I 
learned the following : 

That on or about the 7th day of November he stole a 
watch ; made rational effort, and did escape ; was afterward 
captured and taken to the 57th Street Court. Here he pled 
not guilty to the charge, and signed his name to the paper. 
That night he was reported by the prison keepers to have 



404 



M. D. FIELD. 



made an outcry, and to have had "a fit." After that he 
would not speak or eat, and was stolid and indifferent ; 
apparently in the same condition as I found him. I saw 
his father, who told me that when thirteen or fourteen 
years of age he received a fall ; could give no definite 
injuries, but that he was laid up five or six weeks ; that he 
had always been moody — at one time gay, at another time 
depressed. Family history negative. His father informed 
me that he had been working for his brother up to the day 
of his arrest ; that he had never observed anything strange 
in his actions until he called upon him in prison. He told 
me that his son had been several times convicted of crime. 
I was informed by the police department that on July II, 
1879. ne was convicted for felonious assault, and sentenced 
to one year in the Penitentiary. On October 16, 1880, he 
was arrested, charged with larceny of gold watch and 
chain ; was found guilty, and sentenced to two years in 
State Prison; that on November I, 1882, he was charged 
with same offence ; found guilty and sentenced to six years 
in the State Prison ; was discharged in April, 1887. Noth- 
ing was known of him from that time until the present 
charge. At the time of arrest, on the present charge, was 
perfectly rational, and made offer to return the watch, or 
see that it was returned, if not prosecuted. The friends of 
J. D. and the authorities at the Tombs became alarmed at 
the manner in which he was running down, and the prison 
officials were anxious to get rid of him ; but, owing to the 
peculiar report of the two physicians who had examined 
him for the District Attorney, who stated that he was in a 
cataleptic condition and not fit to be tried, yet not stating 
that he was either sane or insane, he could not be disposed 
of by trial ; it was a difficult problem to know what to do 
with him. Being convinced that the man was feigning 
everything. I was anxious to have him sent to Bellevue 
Hospital for observation. He was finally sent to Jefferson 
Market Prison on December 29, 1887. 

After this I lost track of him until one morning I saw 
an article in one of the daily papers, headed "The Silent 
Man departs, - ' and then learned that he had managed to 



FEIGNED INSANITY. 405 

saw out a bar and made good his escape, on the night of 
February 5, 1888. He was aided in escaping by one John 
Mack, who was recaptured and sentenced to three months 
in the Penitentiary. The other day I had an interview with 
Mack, and learned that for nearly a month he had been 
talking with the prisoner ; and that he had aided him in 
this deception, as he would keep watch and thus allow him 
to move about and get a little relaxation ; if anybody 
approached, he would communicate with him and, of 
course, he would assume his old attitude. 

I have reported this case on account of the interest it 
has been to me ; not so much from the correctness of its 
simulating any particular form of insanity, as for the per- 
sistent maintenance of the condition assumed for so long a 
time. He must have lost from one-fifth to one-quarter of 
his entire weight by simply depriving himself, voluntarily, 
of food. And the wonderful power that he displayed of 
maintaining such a given attitude ; the fixed stare being 
kept np constantly for weeks and even months. The man- 
ner in which he could have pain inflicted without any 
expresion of pain or anger was wonderful. 

Considered as a type of insanity, it was very true to that 
form of insanity described as stuporous insanity, or acute 
dementia. That form of insanity frequently begins sud- 
denly and after some shock. Had an innocent person been 
cast into prison, or had a guilty man been brought up 
short for the first time, one could easily see that the shock 
would be sufficient to produce that form of insanity in a 
predisposed subject. Catalepsy appears with that form of 
insanity frequently. I did not find catalepsy, but two 
physicians, employed by the District Attorney, had so 
reported. The total indifference, stolidity, refusal of food, 
and refusing to speak, are all characteristic of that condi- 
tion ; the evident diminution of the secretions could be 
taken as an objective indication of this condition, for it 
really seemed very small, even in comparison with the 
small amount of food taken ; the small and rather quick 
pulse ; the slow and shallow respiration : the coolness of 
the skin ; the temperature, if anything, being lower than 
normal. 



406 M D - MELD. 

The question might be asked: "Was not this nearer a 
case of melancholia with stupor?" To this we must reply 
that the attitude and expression was more one of stupidity 
than one of depression. There is more evidence in this 
form of insanity of knowledge of the surroundings than in 
one of stuporous insanity ; and it is usually believed that 
the attitude of one suffering from melancholie avec stupor 
is maintained by the patient because he is dominated by 
some delusion ; and we would not expect such a sudden 
onset as in this case. 

On the other hand, the points against this being a case 
of a genuine stuporous insanity seem to me to be the fol- 
lowing : 

There was a strong motive for simulation ; five to ten 
years in prison was staring him in the face ; and the fact of 
this being his third conviction for this offence, he was likely 
to get the full penalty of the law. His family history, as 
given by his father, showed no predisposition ; his rational 
actions up to and shortly after his arrest, while he showed 
insensibility to pain and to reflex action when he could 
prepare himself for and use his will, yet when off his guard 
his reflexes were all found to be normal, his pupils being 
actively responsive ; though he swallowed mechanically, 
yet the readiness with which he did take food after it was 
placed in his mouth, if not indicating volition, showed very 
good reflex action. Though his pulse was small and his 
hands cool and his bodily temperature probably a little 
subnormal, he had not the deeply congested and clammy 
hands so common in cases of dementia. 

Again, the stuporous insanity is rarely met with in per- 
sons over twenty-five years of age. Finally, if this was not 
a case of stuporous insanity, acute dementia, or melancho- 
lia with stupor, it would have to be rejected as coming near 
any form of insanity. 

A fellow prisoner who was recommitted to the Tombs, re- 
ported that he saw this man a year and a half later looking 
well and prosperous. 



gcvtscope. 



CRAXIO-CEREBRAL TOPOGRAPHY. 

By C. L. DANA, M.D. 

The writer has frequently received requests for copies of 
the accompanying rules, originally published in the Medical 
Record, January 12, 1889, and ventures, therefore, to repro- 
duce them here. They have been carefully revised, and 
condensed to some extent. 

I have also added directions regarding the method of 
tapping the ventricles and of reaching the internal capsule. 

A very good cyrtometer has been made for me by Meyro- 
witz Brothers, Fourth Avenue and Twenty-third Street. 

RULES OF CRANIO- CEREBRAL TOPOGRAPHY. 

Rule I. The longitudinal fissure. — This corresponds with 
the naso-occipital arc. 

Rule II. The fissure of Rolando. — (a) The upper end. 
Use the cyrtometer as directed ; or, measure the distance 
from the glabella to the inion ; find 55.7 per cent, of this 
distance, and the figures obtained will indicate the distance 
of the upper end of the fissure of Rolando from the glabella. 
As the naso-occipital arc ranges from 28 to 38 ctm. (11 to 
15 inches), the point sought for lies from 15.7 to 26.8 ctm. 
(6-L to 10^ inches) from the glabella. 

(b) The course of the fissure. Starting from the upper 
end of the fissure, lay off with the cyrtometer a line forming 
an angle of sixty-seven degrees anteriorly with the longi- 
tudinal fissure. This gives the direction of the upper two- 
thirds of the fissure, or for about 5.6 ctm. {2\ inches), The 
lower third, about 2.T ctm., is slightly more vertical. The 
bend of the fissure is about on a level with the anterior end 
of the parietal fissure. The total length of the fissure aver- 
ages 8.5 ctm. (3f inches). 

if) To find the lower end more exactly, if needed: Lay 
off a line from the stephanion to the asterion, and another 
from the bregma to the external auditory meatus. The 



^Og PERISCOPE. 

point of intersection will be just over the lower end of the 
fissure. It should be about I ctm. above the fissure of 
Sylvius. The asterion is usually easily felt just behind the 
upper part of the mastoid process. 




\Camld.** 



Fig. i. — Showing Landmarks on the Skull. 



Control Measurements and variations. — The upper end of 
the fissure is about 48 mm. (if inches) behind the bregma. 
The distance is 45 mm. in women and from 30 to 42 mm. 
in infants and young children respectively. 

The lower end of the fissure is from 25 to 30 mm. (1 
to If inch) behind the coronal suture. The fissure does 



PERISCOPE. 409 

not extend down so low in children, and is a little more 
vertical. 

Rule III. To find the fissure of Sylvius. — Draw a vertical 
line from the stephanion to the middle of the zygoma. 
Draw a horizontal line from the external angular process 
to the highest part of the squamous suture ; continue this 
back, gradually curving it up till it reaches the parietal 
eminence. The junction of the two lines will be at the 
beginning of the fissure of Sylvius. The vertical line indi- 
cates nearly the position of the anterior or vertical branch 
of the fissure, which is, however, directed a little more for- 
ward, and is about 2.5 ctm. (1 inch) in length. The pos- 
terior part of the line indicates the position of the posterior 
branch of the fissure. The triangular gyrus and motor 
speech-centre lies just anterior to the vertical branch of 
the fissure. The operculum lies just back of it. The tip of 
the temporal lobe reaches nearly as far forward as the 
posterior edge of the orbital process of the malar bone. 
The fissure of Sylvius is separated from the lower end of 
the precentral sulcus by a convolution 1 ctm. wide on the 
average (Horsley). 

Control Measurements and Variations. — Reid's method of 
finding the fissure of Sylvius is to " draw a line from a point 
1^ inch behind the external angular process to a point § inch 
below the parietal eminence. The ascending branch starts 
from a point f inch back from the anterior end of this line, 
and 2 inches (5 ctm.) back of the external angular process." 
Dr. Hare draws a line from the external orbital process 
to the inion. A point \\ inch behind the anterior end of 
this line marks the beginning of the fissure, and a straight 
line from here to the parietal eminence marks the course of 
the posterior or main branch. 

The fissure of Sylvius runs nearly horizontally, and lies 
either under or a little above the uppermost part of the 
parieto-squamous suture. This suture, the external orbital 
process, and the parietal eminence are the guiding land- 
marks by help of which the surgeon can often operate with- 
out marking down lines on the scalp. 

In children the fissure is some fi mes higher and more 
oblique. 



410 PERISCOPE. 

Rule IV. To find the parieto-occipital fissure. — Find the 
lambda, mark a point 3 mm. anterior to it, draw a line 
through this at right angles to the longitudinal fissure, 
extending about 2.25 ctm. (1 inch) on each side of the 
median line. This marks the net of the parieto-oceipital 
fissure. If the lambda cannot be felt, its position may 
be found by measuring the naso-occipital arc, and taking 
22.8 per cent of it. This indicates the distance of the 
lambda from the inion or external occipital protuberance. 
The average distance in male adults is 7.42 ctm. (2^ inches). 
It is greater in women, by a little over a millimetre, than 
in men. 

Control Measurements and Variations. — The position of 
the fissure ranges from just under the lambda to as much 
as 12 mm. (£ inch) in front of it. 

It is rather further in front, proportionately, in young 
children, and, according to Fere, in women. 

Rule V. To find the interparietal sulcus. — First mark- 
out the lines for the fissure of Rolando, fissure of Sylvius, 
and parieto-occipital fissure, and mark the position of the 
parietal eminence. Find a point on a level with the bend 
of the fissure of Rolando, and about 2 ctm. (f inch) behind 
it. From this draw a curved line up and back, keeping it 
half-way between the fissure of Rolando and parietal emi- 
nence as it ascends, and half-way between the parietal 
eminence and longitudinal fissure as it passes back. Con- 
tinue the line back till it reaches a point just outside the 
external end of the parieto-occipital fissure. This fissure 
divides the parietal lobe into a superior and inferior lobule. 
The parietal eminence lies over or a little behind the supra- 
marginal gyrus, and about over the middle of the inferior 
parietal lobule. 

Control Measurements. — This fissure has a most variable 
arrangement, and no absolute rule can be laid down. 

Its anterior inferior end is about an inch from the angle 
formed by the prolongation of the fissures of Rolando and 
Sylvius. 

Ride VI. To find the inferior precentral or vertical sul- 
cus, and the inferior frontal and superior frontal sulci. — The 



PERISCOPE. 4 I I 

inferior precentral or vertical sulcus passes nearly verti- 
cally just posterior to the coronal suture. Its lower end is 
i ctm. above the Sylvian fissure (Horsley), and 2 mm. 
behind the coronal suture. Its upper end reaches to the 
level of the mid-point of the fissure of Rolando, and is 4 
mm. behind the coronal suture. It lies 2 to 2.5 ctm. ante- 
rior to the fissure of Rolando. 

The inferior, or second, frontal sulcus passes forward 
from the precentral sulcus at a point a little above the 
stephanion. It continues forward in a line nearly identical 
with the frontal part of the temporal ridge (Reid). 

The superior, or first, frontal sulcus begins at a point 
half-way between the fissure of Rolando and a line pro- 
longed up from the inferior precentral sulcus (Horsley). 

This point should be from 2 to 2.5 ctm. in front of the 
fissure of Rolando. The fissure passes forward parallel to 
the longitudinal fissure, and its line, if prolonged, ends in 
the supra-orbital notch (Reid). 

Rule VII To outline the frontal lobes. — The anterior 
end of the frontal lobes reaches to a point determined by 
the thickness of the frontal bone. This ranges from 2 to 8 
or more mm. -fa to (1 in.). 

The floor of the anterior fossa reaches in front to a level 
a little above the supra-orbital margin (16 mm., f in., Heft- 
ier). It slopes down and backward, its posterior limit being 
indicated by the lower end of the coronal suture. 

Rule J 'III. To find the temporal lobe and the first and 
second temporal sulci. — The temporal lobe is limited above 
by the fissure of Sylvius, below by the contour line of the 
lower border of the cerebrum. This corresponds to a line 
drawn from a point slightly (about 12 mm.) above the 
zygoma and the external auditory meatus to the asterion, 
and continued on along the superior occipital curve to the 
inion. The anterior border of the lobe corresponds to the 
posterior border of the orbital process of the malar bone. 
The posterior border of the temporal lobe is somewhat 
arbitrarily found by drawing a line from the Sylvian fissure 
line at a point 2.5 ctm. below the parietal eminence, back- 
ward and downward to the anterior occipital fissure. 



412 



PERISCOPE. 



The temporal lobe is about 4 ctm. (if inch wide) at the 
external auditory meatus. A trephine, as Bergmann states, 
placed half an inch above the meatus would enter the lower 
part of the lobe. The middle of the lobe is in a vertical 
line from the posterior border of the mastoid process. A 
line from the upper end of the fissure of Rolando to the 
point of the process would pass through this important 
sensory area. 

A point just over the posterior part of the first temporal 
gyrus is found (Barker) by drawing a line \\ inch long 
horizontally back from the external meatus, and then 
erecting a vertical i-t inch. At this point the skull is some- 
times trephined in mastoid disease. 

The first temporal gyrus is about 1 inch (2.5 ctm.) wide ; 
the second temporal is a little narrower (Reid). 

Rule IX. To find the occipital lobe and anterior occipital 
fissure. — The upper anterior border lies under a line drawn 
from just above the lambda (1 to mm), curving out and 
down to a point about at the junction of the anterior and 
middle third of the line from the inion to the asterion. The 
lower border corresponds pretty closely to the superior 
occipital curved line. The anterior occipital sulcus when 
present, should lie in the anterior border of the lobe. 

Rule X. To find the position of the central ganglia, viz., 
corpus striatum and optic thalamus, draw a line from the 
upper end of the fissure of Rolando to the asterion, prac- 
tically a vertical line. This limits the optic thalamus pos- 
teriority. A vertical line parallel to the first, a little in 
front of the beginning of the fissure of Sylvius, limits the 
corpus striatum anteriorly. A horizontal plane 45 mm. 
(if inch.) below the surface of the scalp at the bregma, 
limits the ganglia superiorly. The ganglia lie about 35 mm. 
(if inch) below the superior convex surface of the brain 
(Fere). 

Rule XI. To reach the internal capsule {in its anterior 
part), and the common seat of cerebral h&morrhagc.~Dr. C. 
K. Mills suggests trephining over the temporal lobe poste- 
riorly and low down, then passing the exploratory-needle 
forwards and inwards. 



PERISCOPE. 4 1 3 

A better way, according to experiments made by myself, 
is to find the mid point between the extremities of the basal 
ganglia {vide Rule XL). Then trephine, at a point about 
3 ctm. (i^ inch) from the median line, and plunge the 
needle directly down and slightly outward, for a distance 
of 4 to 6 ctm. (\\ to 2\ inches). 




Fig. 2.— Showing the Course of the Arteries of the Scalp and Dura Mata. 

Rule XII To reach the lateral ventricles.— A number of 
routes may be taken. The lateral is recommended by 
Keen. Mark a point i^ inch behind the external auditory 
meatus, and i^ inch above a base line made by drawing a 
line through the lower border of the orbit and the external 
auditory meatus. 

Trephine at this point and plunge the director into the 
brain in the direction of a point 2\ to 3 inches vertically 
above the opposite external meatus. 

The ventricle lies at a depth of 2 to 2\ inches (5 to 5.7 
ctm.). 



414 



PERISCOPE. 



Rule XIII. To avoid the meningeal arteries and central 
sinuses. — The course of the middle meningeal artery has 
been described and is seen in Fig. 2. This artery is the 
only one of importance or very definite course. The supe- 
rior longitudinal sinus generally (not always) lies a little 
to the left of the median line. The torcular Herophili lies 
approximately under the inion. The lateral sinus lies gen- 
erally under the line from the inion to the asterion, and just 
grooves the postero-inferior angle of the parietal bone. 

Rule XIV To outline the base of the brain. — The rules 
for this are given in Rules VII. , VIII., and IX., for finding 
the frontal, temporal, and occipital lobes. 




Fig. 3. — Showing the Relations of the Cranial Surface to the Convolutions 
and Cortical Centres. 



Society Reports. 



NEW YORK NEUROLOGICAL SOCIETY. 

Stated Meeting, Tuesday Evening, April i, i8go. 
The President, Dr. Geo. W. JACOBV, in the chair. 
Dr. M. D. Field presented a report of a 

CASE OF FEIGNED INSANITY. (See p. 4OI.) 

Dr. FlTCH said that malingerers could not feign mania 
and melancholia so successfully as they could the condition 
of stupor. It was difficult for examiners to determine the 
■exact nature of the case, when the latter state was simulated, 
for obvious reasons. He related some instances of feigned 
insanity that had come under his observation. 

Dr. INGRAM referred to a case described by Esquinol 
which was similar in many respects to that of Dr. Field. 

Dr. SACHS recalled an interesting case that he had 
observed in Westphal's clinic nine years ago. The motive 
of the patient was to escape military duty. The man was 
twenty-two years of age. He became suddenly mute for 
six or seven months. There were no other symptoms. 
All the military physicians had either agreed that the man 
was insane or suspected that condition. He was sent to 
Prof. Westphal. At this time he further simulated a con- 
tracture of the right leg. It was impossible to surprise him 
at an unguarded moment, for even at night they would 
invariably find the contracture present. He would so 
envelop the limb in the bedclothes that any attempt at 
•examination would awaken him. Finally an officer was 
hidden in a room where the patient was to meet a friend, 
with whom he talked quite freely, and the malingering was 
thus discovered. 

Dr. Fisher thought it would be impossible for any one 
to say whether a person was insane or not when in a con li- 
tion such as had been described by Dr. Field, unless the 
person were under constant observation. Simulators seemed 
to be more often found in the classes of feeble-minded and 
imbecile, or in those with hereditary neurotic taint. 

Dr. LESZYNSKY related an interesting case of deception 
practised by a woman with chronic mania. She inserted a 
piece of glass into her arm, which one of the physicians in 
the asylum removed by operation. She then claimed that 
there was another piece in a neighboring spot, and this too 
was located and removed. This was repeated over and 
over again quite a number of times before it was ascertained 



41 6 SOCIETY REPORTS. 

that she was herself inserting the pieces of glass into her 
flesh. 

Dr. Dana had seen stuporous forms of insanity, at Belle- 
vue, often associated with catalepsy. They were a species 
of katatonia. In cases of simulated catalepsy there was an 
excellent test which he had made use of to discover the 
simulation. It consisted in placing the supposed cataleptic 
before another patient in the familiar attitude with his 
fingers to his nose. This position appeals to the sense of 
the ridiculous to such an extent that the simulator will 
finally break down, as a rule ; of course, the true cataleptic 
remains unaffected. 

Dr. G. M. HAMMOND then read a paper upon 

THE RATIONAL TREATMENT OF SCIATICA. (See p. 333.) 

Dr. Dana thought that the author of the paper had done 
good service in calling attention to the fact that rheumatism, 
gout, and syphilis were not causative elements in sciatica, 
but merely diatheses, at times coincident with the disease 
of the nerve. Almost all cases were of an inflammatory 
nature. There was a minority of cases, however, in which 
there was no actual neuritis, but a pure neuralgia, often 
reflex and due to pelvic irritation, and especially found in 
young women. He believed the treatment outlined to be 
rational. Rest was fundamental, but he had had quite as 
much success with strong counter-irritation, in addition to 
the rest, as with the application of cold. 

Dr. STARR mentioned the fact that acupuncture had been 
employed as a remedy in sciatica, a contributor to the 
" Practitioner" having recently called attention to the 
method, claiming that fluid accumulating in the sheath of 
the nerve might thus be evacuated. He had himself had 
no experience with it. 

The President differed from the author of the paper 
and from Dr. Dana in their statement that rheumatism, gout, 
and syphilis had no particular causative relation to sciatica. 
There was not perhaps so much relation between sciatica 
and gout and syphilis as between sciatica and rheumatism, 
but his experience led him to be convinced of such relation. 
He had also met with a number of cases of sciatica due to 
diabetes ; and if diabetes could do so, why could not the 
rheumatic poison produce a similar sciatic neuritis? 

In treatment he had found the galvanic current very un- 
satisfactory, but the application of cold useful. He had 
also employed ichthyol with considerable benefit. 



SOCIETY REPORTS. 4 I J 

The following officers were elected for the ensuing year : 
President — Dr. Landon Carter Gray. 
First Vice-President — Dr. B. Sachs. 
Second Vice-President — Dr. E. D. Fisher. 
Recording Secretary — Dr. Frederick Peterson. 
Corresponding Secretary — Dr. W. M. Leszynsky. 
Treasurer — Dr. Graeme M. Hammond. 
Councilors — Dr. G. W. Jacoby. Dr. C. L. Dana, Dr. M. 
D. Field, Dr M. Allen Starr, Dr. E. C. Seguin. 
Frederick Peterson. 

Recording Secretary. 

PHILADELPHIA NEUROLOGICAL SOCIETY. 
Stated Meeting, April 28, i8go. 
The President, Dr. S. Weir Mitchell, in the chair. 
Paper of Dr. Bassette. 

DISCUSSION. 

Dr. S. Weir Mitchell. — I was probably the first to 
suggest the use of gelsemium in these affections. I used it 
in a number of cases, and my results were reported in some 
clinical papers published ten or twelve years ago. At that 
time I recommended that it be pushed to an extreme limit 
until the toxic effects were obtained. I have recently ob- 
served some interesting results from the use of this drug. 
In two cases there has been complete cure of spasm of the 
rotatory muscles of the neck. In a recent case at the 
Infirmary for Nervous Diseases great relief has been 
afforded, although the cure is not complete. In another 
case, on which an operation was about to be performed, I 
recommended to Dr. M. Roberts the use of gelsemium in 
full doses. The relief was so great that the patient declined 
operation. 

Dr. Bassette speaks of spasm of the spinal accessory 
nerve. I am certain that very few of the rotatory spasms 
of the neck are pure spinal accessory spasms. I have not 
seen any case where section of the spinal accessory nerve 
caused a spasm of the neck-muscles to stop for more than 
twenty-four hours. I have seen the muscle cut, the nerve 
divided, and the nerve divided and stretched, but I have 
not seen any permanent benefit. The reason for this failure 
is that the rotating muscles of the neck are situated on both 



4 I 8 SOCIETY REPOR TS. 

sides. For example, the right sterno-cleido muscle turns 
the head to the left, while certain muscles on the left side 
of the neck at the back also aid to rotate the head to the 
left, both groups of muscles being combined for rotatory 
movement of the neck. Undoubtedly there are, within the 
brain, centres for rotation of the head, and these centres 
control muscles on both sides. This makes it impossible 
to expect good results from the division of muscles on one 
side of the neck. 

Dr. Charles K. Mills. — Dr. Bassette has called atten- 
tion to the fact that patients suffering from these local 
spasms will often endure large doses of the drug for a long 
time even when a good preparation is used. It seems to me 
that in these cases of local spasm there is a resistance to 
the action of motor depressants similar to the resistance to 
narcotics seen in sensory disturbances. 

One argument against operation is that these diseases 
are due to irritation of the cerebral motor centres ; and 
these centres govern movements, and not muscles. An- 
other reason against operation, as I have pointed out in an 
article in the " University Magazine," are the extremely 
extensive and peculiar connections of both motor and sen- 
sory nerves about the spinal accessory down to the fourth 
or fifth cervical segment. The close connection between 
the occipitalis, major and minor nerves, and the spinal 
accessory is one explanation of the failure of operation. 

Dr. Bassette has wisely pointed out the great variations 
in the effect produced by this drug. I would supplement 
her remarks by expressing the hope that we might soon 
reach some responsible standard preparations, especially of 
the more potent agencies, wherefrom we may at least ex- 
pect uniform results in the same individual and under similar 
circumstances. About the only trustworthy method of 
getting real effects from many medicines is, by gradually 
increasing the dose, the characteristic phenomena are 
exhibited, ofttimes a tedious procedure and fraught with 
painful delays to the sufferer. 

Among the analgesics, tinctures are practically out of 
the question, and fluid extracts only to be used. Of these 
the qualities differ, so that I am now using, whenever pos- 
sible, the normal liquids of Parke, Davis & Co., and with 
very gratifying results. Doubtless other firms can make as 
good, but so far as I know have not yet done so. 

A very valuable effect of the drug gelsemium is to allay 
spasmodic cough, and has given me most comforting aid in 
the coughs complicating the recent influenzas. This, added 
to expectant mixtures, immensely improves them. 



SOCIE TY REPORTS. 4 [ 9 

SPINAL CARIES AND PACHYMENINGITIS IN- 
VOLVING DORSAL AND CAUDA-EQUINAL 
REGION. 

By WHARTON SINKLER, M.D. 

No satisfactory history of the case could be obtained, as 
the woman was demented and none of her friends were ever 
seen. The woman had two prominences of the spinal 
column — one occupying the entire lumbar region, the other 
the upper dorsal. 

The patient was helpless, both legs and arms being 
paralyzed. The legs were flexed upon the thighs, and the 
thighs upon the abdomen. These contractures were prob- 
ably of long standing ; the tendons were contracted, the 
muscles much wasted, and adhesions had formed in the 
joints. 

The reflexes were exaggerated. Sensation was not 
much impaired. She had incontinence of urine. 

Post-Mortem. — At the base of the right lung anteriorly 
a cheesy nodule, about the size of a hickory-nut, was found. 
The upper lobe of the left lung was infiltrated with cheesy 
nodules. Both pleurae were adherent throughout. In the 
anterior portion of the spinal canal, at the seats of the 
curvatures, the vertebrae were eroded, and cheesy deposits 
were found adherent to the dura and pressing upon the 
cord. The dura was thickened at these places. The cord 
is being hardened for microscopic examination. No other 
lesions were found 



CYST OF THE LENTICULAR NUCLEUS. 

By WHARTON S3NKLER, M.D. 

B. H., aged sixty-one, occupation a miner. 

May 24, 1888: Family history negative. The patient 
has enjoyed good health until the present attack. Denies 
specific history. Six years ago the right leg became sud- 
denly paralyzed, and this soon extended to the right arm 
and in succession to the left leg and arm. There is no his- 
tory of injury of any kind. He was unable to speak for a 
short time after the onset of the paralysis, but he soon 
regained his speech. His paralysis has also improved, and 
he is able to walk on crutches. 



420 SOCIETY REPORTS. 

August 17, 1889: Patient is quite unable to walk. There 
is but little motor power remaining in the lower extremities, 
and there is considerable loss of power in the upper ex- 
tremities. Speech is impaired, being slow, embarrassed, 
and somewhat scanning, at the same time indistinct. There 
is a tendency to ready laughter. The patient does not 
believe chat things appear ludicrous, but the laughter is 
only a response to the muscular movements of the face. 
There is dribbling of saliva. The knee-jerk is exaggerated 
on both sides, though there is some contracture of the knee- 
tendons. Theie is also some rigidity of the left arm. The 
pupils are equal, regular, and responsive to light. There is 
no headache, no pain ; sleep is good. Eyesight and mem- 
ory are thought to be impaired, but hearing is unimpaired. 
There is incontinence of urine. 

April 20, 1890 : On the afternoon of April 17th the 
patient had a chill, followed by temperature of 105 . From 
this time until he died, on the 20th, his temperature fluctu- 
ated irregularly between normal and 105^°, and his pulse 
ranged from 108 to 150. Shortly after the onset of the 
attack he vomited several times. He suffered no pain, and 
said he was feeling good. Examination of the thorax and 
abdomen proved negative until shortly before death, when 
signs of pulmonary congestion were present. 

Post-Mortem. — Brain : In the right hemisphere an old 
hemorrhagic cyst, about five-eighths of an inch in length 
and three-eighths of an inch in width, was found involving 
the outer half of the lenticular nucleus about one-third of an 
inch back of its head. Anteriorly it was bounded by soft- 
ened tissue involving to a slight extent the internal capsule. 
Except at this one point, it was almost entirely limited to 
the lenticular nucleus. The internal capsule was not 
affected. The vessels at the base were atheromatous. 

The cord was not examined. 

Both lungs were much congested at their bases pos- 
teriorly. 

No other lesions were found. 

The section of the brain was made in all directions, but 
no lesions found to explain the paralysis. 

DISCUSSION. 

Dr. Charles K. Mills. — The first specimen is of inter- 
est in regard to the possibility of operation. You have two 
isolated lesions and the cord itself has not suffered much at 
either place. It seems to me that if these lesions could 



SOCIETY REPORTS. 42 I 

have been recognized, and MaqEwen's operation of remov- 
ing the posterior arches, and allowing the cord to expand, 
had been performed, it is possible that this woman would 
have been saved some suffering. Even the lesion in the 
cauda-equinal region is a membranous one, and was prob- 
ably operable. 

Dr. James HENDRIE LLOYD. — In the report of a series 
of cases of spinal caries with autopsies, made a year ago to 
the College of Physicians, I attempted to demonstrate the 
reason why in many of these cases we have paralysis of 
motion without the involvement of sensation. In most of 
the autopsies that I have seen, in which there has been 
paralysis of motion without paralysis of sensation, there has 
been an angular curvature of the spine, causing a doubling 
in of the lateral columns, but allowing the posterior columns 
to escape almost entirely. This seemed to me to be a 
satisfactory anatomical explanation of the condition usually 
found. A recent writer explains this in a different way, and 
attributes it to a peculiar distribution of the blood-supply of 
the cord. The case of Dr. Sinkler's, in which there is very 
little anatomical lesion, would seem to point to the possi- 
bility of some interference with the blood-supply of the 
anterior part of the cord as the cause. 

In regard to operation : In most of these cases there is 
considerable thickening of the theca and such deposit of 
fibrinous matter extending -down the spinal canal that I 
think the outlook for operation is not as flattering as it has 
been considered by some who have had but one or two 
cases on which to base their conclusions. 

Dr. Francis X. Dercum. — The fact pointed out by 
Elliot, that the cord shows actual disease only very late in 
these cases, is a very important one, and it indicates, to my 
mind, that in a certain percentage of cases, after other 
measures fail, operation should be considered. If the cord 
is not diseased, and we can give it more room, benefit should 
follow. I recognize that, in the old and long-standing 
cases, operation is out of the question. 

Dr. Wharton Sinkler. — In conclusion, I wish simply 
to remark that this specimen of the cord demonstrates how 
extension may be of service in these cases of caries with 
pressure on the cord of long standing: We see here that 
the cheesy and tubercular deposits are limited to the dura 
mater and have not involved the cord, nor is there any 
adhesion between the dura and the cord at the seat of 
deposit. Stretching may modify the relation of the cord to 
the dura at these points, and, by relieving the pressure on 
the vessels, benefit the nutrition of the cord. 



A New Medical Dictionary: Including all the Words 
and Phrases used in Medicine, with their Proper Pro- 
nunciation and Definitions. By Geo. M. Gould, B.A., 
M.D. Philadelphia, 1890: P. Blakiston, Son & Co. 
Small octavo, 520 pages. Half dark leather, $3.25 ; 
with thumb-index, half morocco, marble edges, $4.25. 
It is an era for coinage of new words, and it seems as though 
this year were one for dictionaries, of every description and serving 
all kinds of etymological purposes. When one can obtain a large 
Unabridged Webster's Dictionary as a premium for a subscr, prion to 
a magazine, or one dollar in money, there is hardly an excuse to be 
without a friend — no matter if the make-up is poor — in case of an 
etymological necessity. 

There are also the already well-known Century, Appletons', and 
National Medical Dictionaries, of broader scientific character, hand- 
somely arranged and illustrated, and so profusely descriptive as to 
be veritable encyclopaedias. All of these serve purposes chieily 
outside of the field of medicine, and therefore permit the work 
under consideration to fit in without really competition. There is a 
decided need for a comprehensive and compact Medical Dictionary. 
This one is to be fully appreciated by the physician and student 
anxious for quick information upon some perplexing and recent 
medical term. 

It is not a mere compilation from other dictionaries, but contains 
the product of patient research through the various periodicals and 
text-books in various branches of medicine, and also contains valu- 
able tables of abbreviations, arteries, nerves, ganglia, bacilli micro- 
cocci, ptomaines, etc. : and all is bound in a handy volume, indexed 
and .arranged as a book to work with quickly. It will meet with 
success and appreciative purchasers. 

Practical Photo-Micrography, By Andrew Pringle, 
F.R.M.S. New York, 1890: Scovill & Adams. Pages 
183, with six plates. 
Unquestionably practical photo-micrography would be of great 
interest and utility to the neurologist, and particularly to the neuro- 
anatomist and pathologist, if he could feel reasonably certain of 
securing even a tolerable photograph of his specimens without de- 
voting weeks or even months of time to it. If photographs could 
be produced which would illustrate the common pathological 
changes which take place in the cerebro-spinal system, and show 
them as the microscopist sees them, photo-micrography would soon 
supersede any other method of illustration. It has been stated many 
times that "photographs do not lie." It is also claimed, whether 
justly or not, that drawings of microscopical specimens are not 
always open to the same criticism. Therefore, if it were possible, 
if from no other reason than this, to produce good photo-micrographs, 
even at the expense of considerable time and trouble, photo-microg- 
raphy would soon be generally employed. 



BOOK REVIEWS. 



423 



Until the methods of producing photo-micrographs have been 
very much more simplified, and made less expensive, the practice of 
the art is only likely to be indulged in by the few who have un- 
limited time and ample means at their disposal. 

It is perhaps a comparatively simple process to photograph a 
microscopical specimen of a fly's foot, or the various bacilli, or a 
transverse section of the spinal cord, but it is an entirely different 
matter to so clearly depict minute pathological changes that the 
observer can exclaim at once, on viewing the photographer's work : 
"This is a photograph illustrating posterior spinal sclerosis, and 
this is gliomatous infiltration of the spinal cord, and this is general 
paresis " This, as far as the reviewer's knowledge goes, has never 
been satisfactorily accomplished. 

The novice, or he who thinks good photo-micrographs can be 
made with facility by any one who possesses a microscope and a 
camera, is soon undeceived, and is perhaps somewhat appalled, by 
reading this work. He will soon find that a great deal of fine appa- 
ratus is necessary, and that a thoroughly practical knowledge of 
illumination, objectives, chromatic and apochromatic lenses, eye- 
pieces, and reflectors is absolutely essential if ultimate success is to 
be achieved. 

The earnest student in photo-micrography will find Mr. Pringle's 
volume very valuable. It deals with its subject in a the roughly 
scientific and yet practical manner. The description of all the 
various pieces of apparatus and how to use them, the selection of 
plates and the various solutions for developing them, are set forth in 
a clear and comprehensible manner. 

The chapter on " Progressive Examples," in which the operations 
for subjects presenting various degrees of difficulty are detailed, is 
very interesting and instructive, and contains many valuable sugges- 
tions wnich the amateur photographer will find it to his advantage 
to carefully peruse. 

Color-correct photography is a subject to which the author pays 
special attention. It is a subject of the gre test importance to the 
neuro-anatomist. Pathological specimens must be stained in order 
that their most salient features may be clearly depicted. The stains 
most favored are hematoxylin and carmine on eosine. Sections, 
when stained in these solutions and then photographed on ordinary 
plates, are exceedingly unsatisfactory, the resulting print appearing 
of a homogeneous blackness. This defect can be overcome, the 
author claims, by the use of ortho-chromatic plates. 

The work, as a whole, is the best and most sensible contribution 
to photo-micrography that has appeared in many years. H. 



BOOKS RECEIVED. 

Physicians' and Students' Ready Reference Series, 
No. 5. Second Edition. 



424 MISCELLANY. 

Electricity in the Diseases of Women, with Special 
Reference to Application of Strong Currents. By G. 
Belton Massey, M.D. Physicians' and Students' Ready 
Reference Series, Xo. 5. Second Edition. Philadel- 
phia, 1890: F. A. Davis, Publisher. 

Ax Experimental Study of Lesioxs, arising from Severe 
Concussions. By B. A. Watson. A.M., M.D. Phila- 
delphia, 1890: P. Blakiston, Son & Co. 



ffclxsccUany. 



NOTICE. 

AMERICAX XEUROLOGICAL ASSOCIATIOX. 

The Council of the American Neurological Association 
announces that the Sixteenth Annual Meeting of the Asso- 
ciation will be held at Philadelphia, Pa., on Wednesday. 
Thursday and Friday, June 4th, 5th and 6th, 1890, at the 
Hall of the College of Physicians. S. E. corner of 13th and 
Locust Streets. 

PRELIMINARY PROGRAMME. 

Drs. S. Weir Mitchell and C. H. Burr, of Philadelphia- 
Spinal Chorea. 

Dr. J. P. Putnam, of Boston — I. Cases of Postero-Lateral 
Sclerosis, with specimens ; reported with special reference 
to the Etiology of the Disease. II. Report on n large num- 
ber of cases of Multiple Neuritis, occurring among seafaring 
men in Northern Latitudes. 

Dr. C. L. Dana, of New York — I. Anterior Myeloma- 
lacia, with specimens. II. Ingravescent Apoplexy. 

Dr. G. M. Hammond — Path. Anat. findings in the orig- 
inal case on which Dr. W. A. Hammond's description of 
Athetosis was based. (Supplemented by report on cases 
by Dr. E. C. Seguin and Dr. E. C. Spitzka. 

Dr. G. L.Walton, of Boston — Contribution to the Study 
of the Traumatic Neuro-Psychoses. 

Dr. F. X. Dercum, of Philadelphia — Lesion of the Pul- 
vinar, with special reference to Wernicke's pupil-reaction. 

Dr. N. E. Brill, of New York — Partial Fracture of the 
Cervical Spine of Twenty-two Years Standing. A contri- 
bution to the physiology of the cord. 



MISCELLAXY. 



425 



Drs. F. X. Dercum and F. W. White, of Philadelphia- 
Case of Paraplegia, etc., relieved by trephining the upper 
dorsal vertebral arches. 

Dr. B. Sachs, of New York — I. Tumor of the Corp. 
Ouadrigem, with special reference to the Oculo-Motor 
Innervations. II. Crus Lesion. III. Preliminary Report on 
the Brains and Cords of two cases of Paralysis Agitans. 

Dr. E. C. Spitzka, of Xew York — Limited Focal Lesion 
of the Pons, with Associated Eye-movement of Paralysis. 

Dr. Phillip Coombs Knapp, of Boston — Brain Surgery 
in Relation to the Localization of Cortical Sensory Centres. 

Dr. Irving Rosse, of Washington — Clinical Evidence of 
the Borderland of Insanity. 

Dr. F. Peterson, of Xew York — Association of Loco- 
motor Ataxia with Complete Nuclear Ophthalmoplegia and 
Muscular Atrophies. 

Dr. C. K. Mills, of Philadelphia — Some Sources of Error 
in Trephining. 

Dr. H. M. Bannister, of Kankakee — Focal Hemorrhagic 
Lesion of Anterior Cerebellar Crus. (Tegmenta Brachium 
or " Bindearm.") 

Dr. B. G. Wilder, of Ithaca — I. Demonstration of the 
Brain of Professor Chauncey Dwight. (In connection, the 
brains of other distinguished scientists will be exhibited.) 
II. The Brain of a Chimpanzee. (In connection with which 
the brains of other Anthropoid Apes will be shown.) 

Dr. S. G. Weber, of Boston — Hysteria and Hystero- 
Epilepsy Treated by Hypnotism. 

Dr. J. T. Eskridge, of Denver — Acute Myelitis'with Optic 
Xerve Atrophy, 

Dr. Henry S. Upson, of Cleveland — A Third Paper on 
Gold Chloride as a Staining Agent for Xerve Tissue. 

Dr. William X. Bullard — Diffuse Cortical Sclerosis of 
the Brain in Children. 

Dr. James Hendrie Lloyd, of Philadelphia — Diphtheritic 
Paralysis, with Special Reference to Treatment. 

Dr. Wharton Sinkler, of Philadelphia — A Case of Insular 
Sclerosis, in which an Attack of Cerebral Hemorrhage 
Arrested the Tremor on the Hemiplegic Side. 

PROPOSAL FOR MEMBERSHIP. 
Active. 

Drs. Horatio C. Wood, J. Madison Taylor, Guy Hinsdale, 
Thomas J. Mays, Edward T. Richert and Morris J. Lewis, 
of Philadelphia; Dr. John Amory Jeffries, of Boston; Dr. 



426 MISCELLANY. 

William C. Kraus, of Buffalo ; Dr. J. K. Thatcher, of New 
Haven ; Drs. J. Arthur Booth, Chas. Henry Brown, Richard 
Mollenhauer, Christian A. Herter and Mathew D. Field, of 
New York ; Dr. James H. McBride, of Wanwatosa. 

A ssociate. 

Dr. Eugene Du Puy, of Paris, France. 

A reception will be given by the Philadelphia Neuro- 
logical Society to the American Neurological Association 
at the Art Club on. Wednesday evening, June 4th, from 8 to 
1 1 o'clock. 

Gr.eme M. Hammond, M.D., 

Secretary and Treasurer. 
58 West 45th Street. 



Prof. William James, of Harvard University, Cambridge, 
Mass., in the capacity of Committee on Census of Halluci- 
nations, of the Society for Psychical Research, desires some 
important data in reference to hallucinations, and will be 
glad to send blanks for this purpose. 

The following question, especially, is desired to be an- 
swered Yes or Xo : " Have you ever, when completely awake, 
had a vivid impression of seeing or being touched by a living 
being or inanimate object, or of hearing a voice; which im- 
pression, so far as you could discover, was not due to any 
external pliysical cause ? " 



They who read medical journals to the exclusion of the 
advertisements make a serious practical mistake. It is 
seldom that their perusal does not prompt the use of some 
forgotten remedy of value, reveals an address mislaid, or 
the superiority of some instrument. 

The Journal's advertisements ARE GREAT REMINDERS. 

They make most journals a possibility, and it is cer- 
tainly an advertiser's due that their various notices shall 
be read. 

It is most urgently requested that the personal friends 
of this journal will aid its advertisers and endeavor to make 
them feel that their support is appreciated. 

Wanted.— Complete file of the Journal of Nervous 
and Mental Disease, bound or unbound, to 1888. 

Special numbers wanted : January, 1888; March, 1889; 
January, 1890. 



VOL. XV. July, 1890. No. 7. 

THE 

Journal 

OF 

4 

Nervous and Mental Disease. 



©rigitrat Articles. 



UNUSUAL CASES OF CHOREA, POSSIBLY 
INVOLVING THE SPINAL CORD. 1 

By S. WEIR MITCHELL, M. D. 

AND 

CHARLES W. BURR, M. D. 

JS., male, white, aged 19, presented himself at Dr. 
. Mitchell's clinic at the Nervous Infirmary, Novem- 
vember 23d, 1889, complaining of constant, involun- 
tary movements of the legs, arms and head. His maternal 
grandmother suffered from chorea for many years, not from 
birth, but while affected gave birth to the patient's mother, 
who was choreic from birth till death. She was always 
sickly. She had three children, of whom one was born 
dead, and another died when about a month old. The 
patient alone survived. She, herself, died of phthisis at 
the age of thirty-five. The father, a hard working man, of 
no bad habits, except occasionally too free indulgence in 
liquor, also died of phthisis. There is no history of other 
cases of chorea, nor of other nervous diseases in the family. 
The patient was born at term ; was a puny infant, and 
was breast-fed. He developed slowly, not beginning to 
walk till between two and three years of age, nor to talk 
until his fourth year. There is no mental deficiency. His 
emotional nature is highly developed He is peevish, and at 
times has attacks of extreme sulkiness. He had measles 
when six years old, but no other serious illness. All treat- 
ment has been without influence. His aunt, a woman of 
sufficient intelligence to notice, says that the choreic move- 
ments began in early infancy, probably from birth. 

1 Read before the American Neurological Association, June, 1890. 



428 S. WEIR MITCHELL AND CHAS. W. BURR. 

Present State. — A fairly built young man of good strength, 
and weighing 130 lbs. Appetite and digestion are good; 
bowels regular, and sleep undisturbed. Thoracic and ab- 
dominal viscera show no signs of disease. K. J. is increased 
on both sides, 7 right and 9 inches left. The cremasteric, 
sole and abdominal reflexes are marked. Ankle clonus is 
occasionally present. At times there is a rigidity at the 
knee and the feet are then turned inward at the ankle. All 
of the above are increased by emotion, and by the adminis- 
tration of moderate doses of strychnia. In the right hand 
the dynamometer registers 140, and in the left ioo°. Sen- 
sation to touch, pain and temperature is normal. So also 
is station. 

While awake, his entire voluntary muscular system is 
more or less in action. The corners of the mouth twitch, 
the eyebrows are raised and lowered, the head turned from 
side to side, the shoulders shrug, the arms and legs move 
hither and thither. The muscles of the thorax and abdo- 
men act irregularly in respiration. Speech is somewhat 
hesitating, as if he could not control the vocal muscles. 
Motion and emotion greatly increase the movements. For 
example, if told to write, at the beginning he will do quite 
well, but soon the writing becomes an illegible scrawl, and 
the arms and legs are jerked wildly about. 

Again, if he is suddenly brought in the presence of a 
stranger, the motions are increased. During sleep he is 
perfectly quiet. There is no tenderness over the spine. The 
urine is normal. His eyes were examined by Dr. De Schwei- 
nitz, and showed the following condition: Vision— 1. In 
each eye oval, healthy nerves, and retinas normal. Inter- 
nal recti insufficient 4 . At times slight convergent squint,, 
but diplopia absent. Expression anxious. Electrical re- 
action of muscles normal. 

Case II. W. L., male, white, married, aged 46, machinist. 

When patient's father was about 45 years old, he began 
to suffer from a spasm of the legs, occurring only when in 
bed. The legs would be flexed on the thighs, and the 
thighs on the abdomen, and then the whole would be again 
extended. No pain, but sleeplessness. On walking, move- 
ments would cease. The legs only were affected. The 
disease persisted until death, which occurred in his sixty- 
second year. The cause of death was "enlargement of the 
liver." 

The patient's mother was healthy. He has had eight 
brothers and sisters, of whom three are dead One brother 
(an account of whom is given later) has an affection simi- 
lar to that of the father. 



UNUSUAL CASES OF CHOREA. 429 

Patient had ague twenty-four years ago. Xo other se- 
rious illness, Xo rheumatism. He has had five children, 
of whom three are living. He has never used tobacco nor 
has he indulged in excessive venery. No syphillis. 

The present trouble began in his twenty-first year. He 
first noticed that when in bed his head would be suddenly 
jerked to the left shoulder, and a little backward. This 
would happen several times in the night. The muscles of 
the neck were sore and tired. About ten years ago he no- 
ticed irregular movements in the abdominal muscles, and 
jerking of the right arm. The affection has continued ever 
since. 

Present State. — General aspect is good. Weight 190 lbs 
Digestion, appetite, bowels, sleep and intelligence all nor- 
mal. Temper, bad. Expression, anxious. When sitting 
at ease the right shoulder drops. His head is drawn sud- 
denly back ; chin pulled a little up and to the left, and the 
right ear approaches the right shoulder. Pain in the right 
sterno-mastoid. Painful spots on the outer side of the right 
clavicle, and above the scapula. All the muscles at the 
back of the neck are stiff. Both sterno-mastoid muscles 
are enlarged and hard. Circumference of the neck formerly 
14 inches, now 19 inches. Spine curved, convexity to the 
left. 

The right hand is alternately flexed and extended on the 
wrist; sometimes 12 times in five seconds ; sometimes only 
occasionally and, at rare intervals is perfectly quiet. This 
movement is communicated to the entire arm. Extension of 
the arm increases the movements. He cannot carry a glass of 
water to his lips without spilling it, and often drops the 
glass. On the other hand, he can hammer well holding the 
chisel in the left hand, and never make a mistake. When 
writing, the elbow is held high in the air, the wrist back of 
the little finger is pressed hard on the table, the fingers are 
squeezed together. The first few words can be read, but 
soon a scrawl is produced. The abdominal muscles are 
also affected. The legs and left arm are free. K. J. is slight, 
but very reinforcible. Xo clonus. Dynamometer, R. 135; 
L. 135. Sensation normal. Some numbness in fingers of 
right hand. There is also working of the eyes and frown- 
ing. Electrical reaction normal. 

CASE III. J. L., brother of W. L., aged 52, truck farmer, 
married, two children. 

When a child had Pott's disease so badly that he became 
paraplegic. He recovered sufficiently to walk. Xo other 
illness. 



43Q 



S. WEIR MITCHELL AA'D CHAS. IV. BURR. 



Present trouble began twenty years ago with sudden, 
but not rapid, flexion and extension of the legs and thighs. 
At the same time there were cramp pains in the calves, which 
have continued ever since. The movements occur only 
when sitting or lying, either on the back or side, and are 
worse before, but not during, a storm. No trouble in walk- 
ing, except that on starting there is a slight rigidity in the 
knee. Similar movements of flexion and extension of the 
forearms began about seven years later, without pain. 

For the last two years he has been unable to retain his 
urine. Bowels are loose, but can be controlled. 

Present State. — While observed, patient was quiet. Pa- 
tient is a thin, wiry man. Kyphosis in the mid- dorsal region 
very marked. No palsy, no wasting. K. J. O. but reinfor- 
cible. No plantar nor cremasteric reflex. Healed sinus on 
the anterior aspect of thigh and on the inner aspect. 
Dynamometer, R. 180; L. 180. Station good with eyes 
shut or open. Sensation good. No rigidity. General health 
good. Emotion has no effects upon the movements. 

The first o-f these cases is extremely rare. It is certainly 
very unlike the common chorea of childhood, which, 
under proper treatment, is recovered from in a few weeks 
or months ; and is also unlike the cases of Huntington in 
being congenital and in the absence of marked mental 
symptoms. 

That organic changes are present somewhere in the 
motor tract of the patient, may, we think, be admitted, be- 
cause of the extreme chronicity of the affection, its resist- 
ance to all treatment, and the presence of very distinct 
ankle clonus and rigidity, these latter symptoms pointing 
to the involvement of the spinal cord. Whether, however, 
the changes are confined to the cord is a more difficult 
problem to solve. In the dog, in whom the disease is very 
similar to that found in this man, section of the cord does 
not stop the movements, and in it are found, except in the 
beginning of the trouble, organic changes. 

In the patient, too. the movements bear a certain resem- 
blance to those in dogs. This, however, is admittedly not 
a very strong argument. The involvement of the face seems 
to be. against the view that the trouble is simply spinal. 

In the second and third cases it is, of course, impossible 






UNUSUAL CASES OF CHOREA. 43 I 

to determine whether the father had really choreic move- 
ments. Further, the inheritance has been only general and 
not specific, for the patients were born before the father was 
affected. 

In the second case the chorea is complicated by spas- 
modic wry neck. Indeed, one might say that it was simply 
one of those cases of spasmodic torticollis in which the 
spasm has extended to other muscles, were it not that the 
movements are distinctly choreic. 

As to its morbid anatomy we can say nothing. 

In the third case, we think that the affection is probably 
purely spinal, but is not so distinctly chorea, rather a 
choreic form of spasm. 

It will be observed that we have been careful not 
to assert our belief in more than the probability of the 
spinal cord having been concerned in the production of the 
peculiar spasmodic movements described. We have wished 
most of all to call attention to the cord as possibly the 
parent of certain forms of choreoid disturbances like those 
seen in the familiar canine chorea so well studied by 
Horatio Wood and others. 



A CASE OF PSYCHIC PARESIS, WITH AUTOPSY. 

The following is related by Dr. Inglis in the " Proceed- 
ings of the Detroit Medical and Library Association," 1889: 
An adult male, with unknown history, was seen in a state 
of mental torpor and apparent right-sided paresis. He 
appeared to understand questions, but could only bring his 
mind to bear on any subject a moment. After protruding 
the tongue he would fail to withdraw it, and in shaking 
hands would forget to let go. His answers were appropri- 
ate, but monosyllabic. The paresis was not a true one, 
movements of the right side being performed when speci- 
ally ordered. At the autopsy an infiltrating tumor was 
found in the white substance of the left anterior lobe, lying 
chiefly under the middle frontal convolution. A smaller 
tumor was also found in a corresponding position on the 
right side and an infiltrating deposit of the same growth 
existed on the surface of the corpus callosum. ("Medical 
Record," March 22, 1890). A. F. 



CONTRIBUTION TO THE STUDY OF THE 
TRAUMATIC NEURO-PSYCHOSES. 

By G. L. WALTON, M.D., 

Instructor in Diseases of the Nervous System, Harrard University; Physician to the Neuro- 
logical Department of the Massachusetts General Hospital. 

THE pathology and prognosis of the injuries inflicted 
upon the nervous system by railway collisions and 
similar accidents, have furnished, perhaps, as much 
material for discussion, during the past decade, as any 
other subject in medical science. The diversity of opinion 
on this subject is peculiarly unfortunate, in that it is not 
merely one of scientific interest, but one of great practical 
importance. 

It is curious that the first impetus was given to this dis- 
tinctly neurological subject by a surgeon, and that his views 
should have been for so long a time adopted, practically 
unchallenged, as to have become largely incorporated into 
the text-books of neurology (Erb, Gowers, Ross) as well 
as surgery. 

Under the influence of Erichsen's views, functional and 
organic injuries were for a long time indiscriminately classed 
together under the ambiguous and misleading term, spinal 
concussion, and a common prognosis was given to all, vary- 
ing, it is true, in its possibilities, from death to recovery, 
but leaving the student in doubt, whether there were any 
method of forming even a probable opinion in a given case, 
as to whether the worst or best result might be expected. 

To Page 1 is due the credit of elaborately correcting this 
inaccuracy, and of sifting out the comparatively rare cases 
of organic spinal disease, whose sad course and prognosis 
had been so long allowed to overshadow and include the 
more common cases in which no demonstrable lesion 
existed. To the latter class he first applied the term 

1 Injuries to the Spine and Spinal Cord : Herbart \V. Paye, A.M., M.C., 
1883. 



TRAUMATIC XEURO-PSYCHOSES. 433 

traumatic neurasthenia. The difficulty of injuring the spinal 
cord as long as its bony covering remained intact, was also 
first pointed out by this observer. Since, and largely on 
account of, the appearance of Page's work, a decided, though 
not unanimous, modification of opinion has taken place 
regarding the pathology of these cases, though there is 
still considerable variance regarding their prognosis, even 
among those who have accepted the theory of a functional 
basis for the majority of the cases. 

The advance in our knowledge of the subject has been 
doubly rapid through being gained not only from medico- 
legal observers, but also from clinical investigations in 
hysteria, more especially those of Charcot and his follow- 
ers, whose studies have thrown light on the more stabile 
forms of this protean disease, which has removed the objec- 
tion originally presented, to classing under this head cases 
with symptoms comparatively fixed in seat and character. 
Indeed, as is well known, Charcot at first considered all 
these cases simply hysteria. 

Dr. Putnam," in 1883, after reporting several cases of 
traumatic hemi-anaesthesia, called attention to the import- 
ance of looking for evidences of typical hysteria, in the 
chronic as well as in the acute stages of so-called spinal 
concussion. In the same year, in illustration of the general 
tendency to withdraw the attention from the spinal cord, 
the writer, 3 in a paper on the cerebral origin of symptoms 
sometimes classed under spinal irritation, proposed the 
name "railway brain" as more appropriate than "railway 
spine" to designate the class of traumatic cases under dis- 
cussion. This name has been quite extensively adopted, 
though, as Thorburn comments, it was only a step in the 
right direction. 

Among those who early inclined toward the modified 
views regarding the effects of trauma on the nervous sys- 
tem, may be mentioned Dana,' who, writing in 1883, very 

2 Recent Investigations into the Pathology of so-called Concussions of 
the Spine, etc.: Boston Med. and Surg. Jour.. Sept. 6, 1SS3. 

3 Spinal Irritation: Probable Cerebral Origin of the Svmptoms, etc. : 
Ibid., Dec. 27, 18S3. 

« New York Med. Record, Dec. 6. 1SS4. 



434 G - L - waltox. 

appropriately added hypochondria to the two terms already 
applied, a term widely applicable in view of the morbid 
introspection and self-study which does so much to increase 
and perpetuate the subjective symptoms. This writer, 
while considering spinal concussion a possibility, preferred 
to regard the majority of cases thus designated as traumatic 
hysteria, hypochondria, or neurasthenia, associated more or 
less with symptoms of injury to the vertebral ligaments and 
muscles, and to the spinal nerves. The prospect for im- 
provement he considered good, but not that for perfect 
recovery. 

Spitzka 5 had considered that spinal concussion could 
produce spinal irritation, a disturbance not to be mistaken 
for myelitis or meningitis, but at the same time one whose 
severity should not be lightly regarded. 

These theories were in direct opposition to the idea 
advanced by Westphal 6 of a diffuse sclerosis set up by the 
jar, perhaps through the mechanism of minute hemorrhages, 
as well as to the views of Leyden, which favored organic 
disease as a common sequel concussion. Among the 
followers of Westphal were numbered originally in Ger- 
many Oppenheim and Thomsen, and in America Knapp s 
and others. The conscientious and thorough work of 
Oppenheim in this direction became so generally recog- 
nized that his later conclusions 11 ' designating the majority 
of the cases as neuro-psychoses have had perhaps more 
influence than the efforts of any other writer since Page in 
modifying the general opinion. 

Knapp," in a later article, adopts the classification of 
Oppenheim, though still adhering to the view that certain 
of these cases should be classed under the sclerosis of 
Westphal. 

* Am. Jour, of Neurology and Psychiatry. Aug., 1883. 
c Einige Falle von Erkrankung dts nervou Systems nach Verletzunjj auf 
Eisenbahnen. Charite-Amalen. v. 379, 1878. 

" Klinik der Riickenmarkskrankheiten, B. II., Berlin. I875. 

s Berl. klin. Wochenschrift, 1884 : Archiv. f. Psychiatric 1885, vol. xvi. 

9 Boston Med. and Surg. Jour , Oct. 25, 1888. 

10 Berl. klin. Wochenschrift. 1888, No. 9. 

" Boston Med. and Surg. Jour., Dec. 19, 1889. 



TRAUMATIC NEURO-PSYCHOSES. 435 

Thorburn, 12 in his excellent work on the surgery of the 
spinal cord, states that recent writers are practically unani- 
mous in agreeing that concussion of the spinal cord is at 
least an extremely rare lesion, though there is still much 
dispute as to the significance of the nervous symptoms 
commonly observed after severe physical or physical and 
psychical shocks. His views of the pathology and prog- 
nosis of the disease do not differ materially from those of 
Page, though he draws the distinction more closely between 
hysteria and neurasthenia. 

In a recent work by Clevenger, 1 ' of Chicago, it is pro- 
posed to give to these cases the name "Erichsen's disease," 
in honor of one whose work this author considers, with 
some modifications, standard. This writer regards the 
spinal sympathetic system as the starting point of the 
pathological process, but reverts in general to the spinal 
cord as the principal seat of disease, encouraging also the 
view that myelitis, meningitis, meningo-myelitis, locomotor- 
ataxia, diffuse and lateral sclerosis are not uncommon 
sequelae of trauma. 

Seguin, 14 in his admirable summary of recent progress 
in Sajous' Annual of 1889, based on the articles of Oppen- 
heim, Knapp, Striimpell, Bajinsky, Wolffe and Shaw, con- 
siders organic injury to the nervous system a rarity as 
resulting from the forms of trauma under consideration. 
He lays much stress on suggestion, both hypnotic and non- 
hypnotic, discusses deliberate malingering, and emphasizes 
the prominence of subjective, and absence of objective 
symptoms. He criticises the too common habit of accept- 
ing literally the statements of the patient regarding his 
own sufferings. 

Without exhausting the literature of the subject, it may 
fairly be concluded that there is at present a very general, 
though not unanimous tendency to abandon the theory of 
spinal concussion as at all widely applicable to the class of 
cases under consideration, and to regard the majority of 

12 Contribution to the Surgery of Spinal Cord by Wm. Thorburn, B.S.. 
B.Sc. M.D. (Lond.). 

13 Spinal Concussion, etc., by S. V. Clevenger, M.D. Phila. . 1889. 
>« Vol. Hi. O. 



436 G. L. WALTOX. 

the genuine cases as identical with already recognized 
functional forms of disease, rather than as cases of organic 
spinal injury. 

My own experience has lead me from the first to regard 
disease of the spinal cord resulting from trauma as of com- 
parative rarity, when no dislocation or fracture has occurred, 
while Seguin's conclusion regarding the predominance of 
subjective symptoms, and the degree in which we are gen- 
erally dependent on the patienfs statement, are fully justi- 
fied by the majority of the cases which have come under 
my observation. 

I have especially noted the rarity of such symptoms as 
local atrophy, fibrillary twitching, bed-sores, cystitis, dis- 
turbance of electrical reactions, involuntary rigidity, spastic 
gait, toe-drop, ankle clonus, pupil irregularities, and dis- 
ordered reflex (beyond mere activity, which, as Seguin 
states, is alone bf no diagnostic value). The symptoms 
nystagmus, and incontinence of urine, which Knapp inserts 
in his resume, I have found notably absent. A number of 
the patients have complained, it is true, of retention or 
incontinence, but absence of palpable proof of these symp- 
toms has forced me in every instance of the class of cases 
under consideration, to regard the statement with consider- 
able skepticism. In fact, questioning the patient alone has 
generally sifted down the complaint to frequency or delay 
of micturition, symptoms which are common in functional 
cases, non-traumatic, as well as traumatic, and which, as 
compared to the true retention which causes overflow 
unless the catheter is used or to the true incontinence 
resulting from organic disease, with its attending annoy- 
ances both to the patient and his friends may almost be 
regarded as trivial. Nor do even these mild forms of 
bladder trouble necessarily exist in ever)- case where 
claimed, but they must be reckoned among those symp- 
toms for which we have no evidence beyond the patient's 
statement. In the same category, I should agree with 
Seguin in placing anaesthesia, both general and special, 
and of course, also, hyperesthesia, and paresthesia, as 
well as pain. I have become so convinced that in the case 



TRAUMATIC NEURO-PSYCHOSES. 437 

of a practised simulant the various tests for anaesthesia, 
even including the wire brush, are non-conclusive, that in 
many cases I make no attempt to either establish or con- 
fute the claim, but set it down as a symptom for which I 
have the patient's statement only, just as for the pain, sen- 
sitiveness, bad dreams, and other symptoms ; no one but 
himself knowing whether it is present or not, and in view 
of Seguin's observations regarding suggestion, it may, per- 
haps, in genuine cases, sometimes even be doubtful whether 
the patient himself has any very definite consciousness of 
the exact severity of these subjective symptoms. 

In a similar category, I should place certain symptoms 
occasionally seen, upon which Knapp has laid stress as 
almost of necessity pointing to organic disease ; such are : 
the complaint of a constriction about the waist, swaying 
with closed eyes, tremor, and a staggering gait. The sense 
of constriction may be as easily complained of by the 
hysterical or neurotic patient or the simulant as impotence 
or any other subjective symptom, while swaying, tremor, 
and staggering may occur as symptoms of functional 
trouble or general debility, or again may be easily simu- 
lated. A tremor of the head, for example, may be kept up 
a considerable time without fatigue, by resting the hands 
on a walking-stick upright between the knees, or upon the 
edge of a table. A rythmical movement may be started by 
the arms in this position by which the head is caused to 
oscillate forwards and backwards, the movement being a 
comparatively natural one, and causing little fatigue. This 
variety of tremor, as well as less successful attempts at 
tremor of single extremities, I have seen, where I was con- 
vinced of the presence of simulation. I have also seen a 
voluntary tremor in the leg which was apparently an 
attempt to produce an ankle clonus. 

It will be noted in the resume oi cases following, that a 
large number complained of loss of power. The loss was, 
as a rule, quite generalized, involving one or more entire 
extremities. In some of these cases there was palpable 
fraud, shown, for example, by the patient making with 
ease, when his attention was diverted, the same movements 



438 G. L. WALTON. 

which he had declared himself absolutely unable to per- 
form. In others the loss appeared genuine, while in others 
it was impossible to decide to a certainty whether the case 
was one of fraud or hysteria. In none of the cases which I 
have classed under the neuro-phychoses was the gait char- 
acteristic of organic disease, the foot being generally everted 
and dragged with its whole length scraping the floor, or 
again, the foot would sometimes clear the ground entirely, 
sometimes scrape with the heel as well as the toe, a gait 
which, if genuine, points rather to hysteria than to organic 
disease. In some cases oddities of gait appeared which 
could not be brought under any recognized class of para- 
lytic gait. 

Typical hysterical contracture was present, I think, in 
only one case. 

Allied to the active reflex I have often found a rapid, 
but otherwise normal pulse, a symptom upon which I have 
seen great stress laid in courts, but which has generally 
been either the result of excitement or of weakness, or of a 
neurotic or hysterical tendency, associated, for example, 
with large pupils. In investigating this symptom, I have 
been surprised to find how easily the normal pulse is ele- 
vated to 100 and over, even on moderate excitement. 
Indeed, a pulse-beat of 90 to 100 is by no means an ex- 
treme rarity in a healthy individual, whether male or 
female (though, of course, more common in the